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From the case files

The following case scenario highlights the importance of keeping a broad differential diagnosis, and seeking advice from specialists if you are unsure

Missed ectopic pregnancy

Miss G was a 33-year-old single parent who had two children, aged 4 and 6. She had previously had salpingitis and three weeks ago had had unprotected sexual intercourse. Her periods were overdue by four days, so she had a pregnancy test, which was positive. She made an urgent appointment at a clinic to discuss the possibility of a termination.

When she was first seen in the gynaecology clinic, she was scanned and they were unable to identify an intrauterine sac. She was therefore asked to come back ten days later. When she returned, the scan showed what was reported as “…an 8.5mm intrauterine sac compatible with five weeks gestation”.

The gynaecologist, Dr W, warned Miss G of the risks of having such an early termination, but she insisted that they went ahead with the procedure as soon as possible. Dr W agreed and carried out a surgical termination under local anaesthesia. The procedure was deemed to be uneventful and no histology was requested.

Ten days later, Miss G attended her local casualty with nausea, dizziness and abdominal pains. She was fully examined by the young casualty doctor Dr Y, who thought she had endometritis and gave her some antibiotics, reassured her and sent her home.

A week later Miss G collapsed at home with severe right iliac fossa pain. She was brought back into the hospital by ambulance, hypotensive (BP90/50mmHg) and tachycardic (P 120). She was seen again by Dr Y who suspected appendicitis and requested an abdominal USS and routine bloods (FBC, U&Es). The USS showed a large amount of fluid in the pelvis and abdomen and an empty uterus, and the radiologist suggested carrying out an urgent pregnancy test. This was indeed positive and the gynaecologists were called out to attend to Miss G urgently.

It was deemed that Dr W had offered appropriate counselling to the patient with regards to the risks of the procedure at such an early stage of the pregnancy, although he was criticised for not requesting histology

Two litres of blood were found in Miss G’s abdominal cavity and a ruptured ectopic pregnancy on the right side was confirmed. Her left fallopian tube had scarring from her previous salpingitis infection; regrettably, the right tube could not be conserved. She required a blood transfusion, but made a full physical recovery, although she was quite traumatised by the events that had occurred and was upset by the advice that she might have problems conceiving naturally in the future.

Miss G made a claim against both Dr W and Dr Y. It was deemed that Dr W had offered appropriate counselling to the patient with regards to the risks of the procedure at such an early stage of the pregnancy, although he was criticised for not requesting histology. Dr Y was found to be wanting in not requesting a pregnancy test on each occasion and not requesting advice from the on-call gynaecology team, especially in view of her recent gynaecological surgery.

Learning points

  • When undertaking early terminations at less than seven weeks gestation, it is possible that only decidual endometrium is aspirated rather than the actual gestational sac. As such these procedures must be performed with the appropriate safeguards to ensure that the abortion is complete. Visual inspection of the tissue aspirated is of utmost importance. See: RCOG, The Care of Women Requesting Induced Abortion. Evidence-based clinical Guideline Number 7, London (November 2011).
  • Although terminations are common procedures, as with all surgical procedures, all the common and significant complications must be fully explained to the patients and documented carefully in their notes.
  • Although urinary pregnancy tests may stay positive for two weeks following miscarriage or termination, they should be requested on any female of reproductive age attending ED with gastrointestinal symptoms or unexplained abdominal pain. Gastrointestinal symptoms, particularly diarrhoea and dizziness, in early gestation can be important indicators of ectopic pregnancy.
  • An early pregnancy ultrasound that fails to identify a definite intrauterine sac should stimulate active exclusion of tubal pregnancy. Dr Y had two opportunities to keep a broad differential diagnosis and should have requested a urinary pregnancy test +/- and an ultrasound, and sought advice from the gynaecology on-call team, to exclude an ectopic pregnancy.
  • Even in the presence of a small uterine sac (eg, pseudosac), an ectopic pregnancy cannot always be excluded. See: 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl 1), 1–203.

This case originally appeared in Casebook (Vol. 20 no. 3 – September 2012).