CC Samantha Angela P.

Mata Oct 21, 2022

SG5A
OBGYN rotation
Paper Case 1

Salient Points

Subjective Objective

➢ 18 year old, G1P0 ➢ PE:

➢ LMP: Feb 14, 2022 ○ VS: 90/60 mmHg, HR: 138
○ 6 4/7 weeks AOG (admitted bpm; RR 20cpm; T: 37C
for the first time on ○ pale looking, pale palpebral
Apr 1, 2022 ) conjunctivae,
➢ No known comorbidities ○ Abdominal exam: (+) direct
➢ 2 days PTA: vaginal spotting with tenderness on all
discomfort at the hypogastric area quadrants,
➢ 4 hours PTA: severe generalized ○ SE: (+) cervix violaceous,
abdominal pain, still with vaginal (+) blood from cervical os
spotting, noted to be pale ○ IE: cervix closed, uterus
➢ ROS: (+) dizziness small, (+) cervical motion
➢ MOGSCI: regular menstruation, tenderness, (+) 5x4
currently pregnant, no known centimeter tender mass at
gynecologic infections, coitarche at the left adnexa, (+)
17 years old, no history of post fullness in the cul-de-sac
coital bleeding and dyspareunia, 1 ➢ Ultrasound:
male exclusive sexual partner, no ○ 5x5 centimeter complex
history of contraceptive use mass at the left adnexal
➢ (-) no HPV vaccination, area, ovaries both
➢ Past medical hx: no hx of infection visualized and normal, (+)
or surgeries and hospitalization fluid in the cul-de-sac
➢ Social hx: separated from partner,
Denies use of tobacco, drinking
alcoholic beverages, and use of
illicit drugs

Differential Diagnosis Rule in Rule out

Ruptured Ectopic (+) current pregnancy (-) excessive vaginal

Pregnancy (+) mass at the left adnexa bleeding
(+) direct tenderness on all
quadrants
Small uterus
 (+) vaginal spotting
(+) hypotensive patient

PID (+) abdominal pain in the (-) foul-smelling vaginal

hypogastric area discharge
(+) vaginal spotting (-) dysuria
(-) HPV vaccination

Endometriosis rupture (+) accumulation of fluids (-) dysmenorrhea

in the cul-de-sac (-) dyspareunia
(+) abdominal pain

Diagnosis

Primary diagnosis: Ruptured Ectopic Pregnancy

An ectopic pregnancy occurs when there is extrauterine growth of a fertilized egg.

This is caused by a compromised flow and ciliary motion of the fallopian tube resulting
in the failure of the egg to reach the uterine cavity. Growth, vascularization and
placenta formation tries to proceed, which can eventually lead to rupture in the area.
95% of ectopic pregnancies occur in the fallopian tube (by location Ampullary >
Isthmus > Fimbrial > Interstitial). Risk factors include previous ectopic pregnancy,
abnormal anatomy, previous salpingectomy/salpingostomy and other surgeries,
adhesions, congenital abnormalities, history of STIs and others. Smoking is also a
known risk factor since this slows down the ciliary motion of the fallopian tube. This
can also be caused by contraceptive failures. Rupture of tubal ectopic pregnancies
can occur spontaneously and leave tears in the fallopian tube. This results in
hemorrhage and blood accumulation in the cul de sac. Symptoms of a rupture include
severe abdominal pain, dizziness, pallor, and tachycardia. This is considered an
emergency case and requires immediate surgery.

The patient presented with vaginal spotting, pallor and severe abdominal pain. From
these symptoms, we can consider numerous differential diagnoses. Due to the
involvement of the vagina and the known pregnancy, an obstetric pathology will be
considered. The patient’s symptoms are typical of a ruptured ectopic pregnancy which
was mentioned above. Furthermore, ultrasound findings showed a small uterus
meaning there was no growth of an embryo despite a positive pregnancy test and a
mass at the left adnexa which helps us localize where the embryo implanted.
Moreover, the presence of blood pooling in the cul de sac also increases the
possibility for a ruptured ectopic pregnancy. There is strong evidence to suspect a
ruptured ectopic pregnancy which necessitates immediate surgical management.

Management

Diagnostics TVS
- evaluates the endometrial cavity
- intrauterine gestational sac is usually visible between 4
1⁄2 to 5 weeks
- yolk sac is usually visible between 5 to 6 weeks
- fetal pole with cardiac activity is first detected between
5 1⁄2 to 6 weeks
- absence of normal findings or presence of trilaminar
endometrium could indicate ectopic pregnancy
- (+) hemoperitoneum → blood pools in the cul de sac

urine β-hCG, serum B-hCG

- normal β-hCG levels in non-pregnant patients: 0-5 mIU/mL
- pregnancy tests can detect urine β-hCG as low as 20-25
mIU/mL and serum β-hCG ≤ 5 mIU/mL
- β-hCG levels ≥ 1500 mIU/mL indicate that pregnancy
should be evident upon TVS (e.g. visible gestational sac or
yolk sac)
- if β-hCG exceeds the discriminatory level but no evidence of
intrauterine pregnancy is seen, ectopic pregnancy should be
considered
serum progesterone
- levels < 5 ng/mL strongly suggest either ectopic pregnancy or
a non-living intrauterine pregnancy
Laparoscopy
- Not commonly used
- Direct visualization of the fallopian tubes and pelvis

Therapeutics Medical management: Methotrexate is a chemotherapy drug and is

also commonly used in the treatment of ectopic pregnancy. This
drug stops the embryo from growing, and avoids the need for
surgery. The pregnancy then is absorbed by the body over 4–6
weeks. This is a good option for pregnancies located in the cervix or
the ovary.

Surgical Management: Ruptured ectopic pregnancy however,

definitely requires emergency life-saving surgery. Bleeding is an
indication for surgical intervention. Surgeons use laparoscopy or
laparotomy to gain access to the pelvis and can either incise the
 affected Fallopian tube and remove only the pregnancy
(salpingostomy) or remove the affected tube with the pregnancy
(salpingectomy)

Since the patient is young, and only had the left fallopian tube
affected we would opt to preserve fertility via salpingostomy.

References:

1. UpToDate. "Patient education: Ectopic (tubal) pregnancy (Beyond the Basics)." 21

March 2018. Accessed 20 October 2022
2. Penn State Hershey Medical Center - ADAM. "Ectopic Pregnancy." 9 December
2012. Accessed 20 October 2022.
3. Cunningham F, Leveno KJ, Bloom SL, Dashe JS, Hoffman BL, Casey BM, Spong
CY. Williams Obstetrics, 25e. McGraw Hill; 2018.