Friday, February 19, 2010

Abdominal Pregnancy

A midwife asks me to review a patient.

“She had ultrasound scan, and it shows abdominal pregnancy,” she tells me.
“Abdominal pregnancy? But that is so rare. It can’t be,” I say.
“That is what they have said. But I want you to review.”

An abdominal pregnancy is a type of ectopic pregnancy, but rather than implanting in the fallopian tube or the ovary, the pregnancy implants somewhere in the abdomen. Because the pregnancy size is not limited by a tube or capsule, it can grow quite large before it is diagnosed, into second or even third trimester. However, the blood flow to the placenta is poor, and most untreated abdominal pregnancies end in a fetal demise.

I see the patient. She looks calm and healthy. There is a bulge in her thin abdomen that looks like a second-trimester pregnancy, and it is somewhat tender. I learn that she is 37 years old, and has 5 children. She has been having pain for a while, maybe weeks. I see the ultrasound report, and it does indicate abdominal pregnancy. But could this really be one? They are so, so rare. There was one such case during my residency, and I didn’t manage the patient, but I heard about it.

I go and get the ultrasound from the clinic and repeat the scan. Immediately, I see her uterus, and it is empty. I scan higher in her abdomen, and I find a huge mass. It is dense, solid, and varies between white and grey color. It looks more like an abdominal mass than a pregnancy. I see a small area that has a glow of white that could be bone, but no definitive pregnancy.

I ask if she had a pregnancy test. A midwife helps me to translate, but before I get an answer to my question, she wants to tell me that she has pain, and all about her other complaints. I make a mental note of the symptoms she has told me, and then I ask again about the urine pregnancy test.

I am curious about the pregnancy test because it is possible that she could have a certain kind of ovarian tumor (dermoid cyst) that can be dense, large, and can have pieces of bone, teeth or hair inside. It could be confused with a pregnancy if the ultrasonographer is inexperienced. I also wonder if she has some kind of embryonic tumor or sarcoma that could look like a pregnancy, because I am really seeing a big solid mass.

She says that she did have a urine pregnancy test yesterday, and it was positive. While some tumors can secrete HCG (the hormone that is tested in the urine to detect pregnancy), they are rare. Then again, so is abdominal pregnancy.

I keep scanning, and I go even higher on the mass. Then I see a glimmer of what might be a pregnancy. I focus on it, and I see what looks like a fetal skull. It’s hard to see, but it does look quite distinctively like a skull. It measures to a 17-week size. I also see some sort of long bone, maybe a femur. Because it is surrounded by dense material and not fluid, it is much harder to tell what I am looking at.

I re-read the prior ultrasound report. They report a fetal skull, and fetal spine. They interpret it as a degenerating abdominal pregnancy. There is not fetal heartbeat. I can’t find a spine anywhere. My best guess is that this is a degenerating abdominal pregnancy surrounded by a large amount of clotted blood, but I also keep ovarian tumor within my differential diagnosis.

Now, what to do? The management of abdominal pregnancy is clear – surgical removal. However, it can be extremely difficult and extremely dangerous. The placenta could have implanted anywhere – on intestine, on liver, on blood vessels, on uterus, on any intraabdominal organ. If it implants on the uterus, that’s easy – you do a hysterectomy. But if it implants on a vital organ, it can be very dangerous, and if it implants on a blood vessel, then removing it could cause major hemorrhage. Oy vey.

When we had that abdominal pregnancy in residency, it was a big hullaballoo. The patient was transferred to our larger hospital, the entire Gynecologic Oncology team was involved, there were multiple people (attendings, residents, fellows, anesthesiologists) in the room. The patient had invasive monitoring, large-bore IVs placed, blood and blood products available in case of hemorrhage, cautery and all kinds of intensive care. She might have even had preoperative embolization of the pregnancy in order to reduce the intraoperative bleeding. I have me. Ta-da.

At the moment, the hospital doesn’t even have power. The power bill hasn’t been paid in a while, and the power company shut it off. There was an emergency action taken, and the hospital administration managed to get 24 hours of power while scrounging up money for the bill, and there was power in the morning. But then, the power went out for the whole neighborhood (a regular occurrence here for load shedding). Sigh.

Luckily, the patient is stable. She is somewhat tender, but doesn’t seem to be actively bleeding. One option is to transfer her. We could send her to Mbale (where there is a regional hospital) or Kampala. But “transfer” means “tell her to go” – which means she has to pay to get herself there. Once there, who knows what will happen. She might have to pay for all her medications, or other supplies. She might encounter someone who will require a bribe to admit her or treat her or perform surgery. I ask the Ugandan medical students working with me whether this is the case, and they say “Well, this is Uganda. These things happen. Yes, probably this will happen.” I can’t say my own country’s system is a whole lot better - we treat you, but then you go bankrupt. I suppose it’s like a bribe after the fact. But at least you will get emergency care.

I discuss the options with the patient. She can be referred, or she can be admitted here and wait for the power to come on. I tell her that her care will be free, but there is less supply here – like available blood and intensive care - that she might need in an emergency. She very firmly states that she will not be referred. She will stay and wait for the power. “She cannot afford to go,” says the medical student who is translating.

I am nervous about this. There is a good chance that this could be surgically very complicated and very, very dangerous. I have never operated on anyone with an abdominal pregnancy. I could probably adapt some of what I have learned, but what if I get into real trouble in the OR? Who would I call? There is no one in Tororo with specialist training. Many of the medical officers have had to operate, so I suppose I could call them. I don’t even know if the cautery in the OR works, and cautery is essential. She could bleed like stink. What if I need blood? I will have to cross match at least 4 units. What if she dies on the table? That would be horrible, horrible. But then….what are my other options? I could force her to go to Mbale – but that’s no better. I’d be sending her to be operated on by someone with probably a 1-year internship, not a specialist. And she might not even get the care if she doesn’t have the money. I would have no certainty that she would be operated on. How could I sleep knowing that I had abandoned the patient like that?

I take a deep breath, and think for a while. I decide to do the case. I will tread lightly. If I get into hot water, I will stop the bleeding and close. I will read up on surgical management of abdominal pregnancy. What else can I do? She could die in the OR, but if I don’t do this, she will die.

We admit her to the Female Surgical ward. I have another operation I need to do as well, so I do a lot of running around to the hospital administrator to see if and when the power will be switched back on, and what my options are. It sounds like there will be power tomorrow.

I check on her in the evening, and she is doing OK. I realize, however, that she is very pale. She has already been cross-matched for blood, so I go to the lab and ask my friend in the lab to check a hemoglobin level. It is 5.3. In the US, this would be insanely low. We would freak out, and transfuse the patient in double time. Here, it is not low enough to warrant transfusion. The hemoglobin needs to be less than 5 (or sometimes even lower) for a transfusion to be indicated. Her heart rate is not elevated, and she is asymptomatic. Of course, we are about to do a huge surgery, so she will likely need blood. At home, sometimes we will preoperatively transfuse the patient, but here blood is so scarce (in fact, it is taken from schoolchildren because of the high risk of HIV in adults, and when school is out, there is no blood to be found). In addition, who knows if the operation will actually happen tomorrow. There might be no power, of who knows what might happen. And lastly, I imagine I would have to argue hard with the lab and the nurses to even get a preoperative transfusion. I decide not to transfuse preoperatively, but I do confirm the cross-match. Luckily, there happens to be a lot of blood in her type available, so even if I need more units, they are there.

The next day, the patient is still doing fine. Since she can’t speak English, I need a nurse to help me translate the consent. She has already given “consent” by signing the form, but I doubt anyone told her the procedure I would be doing, much less that we might remove her uterus and/or tubes and/or ovaries, and that there is a high risk of death.

I go to Female Surgical Ward three times over the course of the morning, but never find a nurse. It gets very frustrating. The patient’s attendant claims to speak English, but when I ask her to translate, she has no idea what I’m saying. I give up.

We schedule the case for 2pm. When the patient is in the waiting area, I bring over a medical student who can translate. Before I can speak, she says something. “She wants a tubal ligation,” translates the medical student. That makes me chuckle a little, since I am about to tell her she might lose all her pelvic organs.

I am very forthright with her. I tell her that I might remove the uterus/tubes/ovaries, I might damage the intestine, other organs. I tell her that there is a risk she could die in the surgery. When I say this, the medical student stops before translating. “I should tell her that?” he asks, stunned. “Yes, she needs to know,” I tell him. He translates, and then I go on to say that I will take every precaution to save her life, including transfusion and anything else we need to do. “She says thank you,” says the medical student. The patient is smiling and takes my hand.

I go to make preparations for the surgery. I pull out all the sutures I might want. I ask the medical student to put in a second IV line. I confirm that the blood is in the OR for transfusion if needed.

A few months ago, a visiting resident bought 2 c-section kits with donated money. I have never seen these nice instruments – I haven’t bothered to fight for them to be used. But now, I will need them. The anesthetist shows me where they are hidden, and they are a glittering treasure trove in my eyes. “We don’t take them out because they will have legs,” he says. But what’s the difference if someone steals them or you never use them? You still have no new instruments.

I pull out all the clamps and forceps and retractors a girl could ever want. I am in heaven. I give them to the OR tech for autoclaving.

Dr. W, one of the hospital doctors, has volunteered to scrub with me and assist in the surgery. I am glad to have a second set of eyes, although cautious because I have never met him. I hope he doesn’t give me flack for being young or female, or that he doesn’t assume I don’t know anything about medicine. As it turns out, I was glad he scrubbed with me. I told him my intraoperative plan as we waited for the OR to be ready – 2 large-bore IVs, blood available, vertical skin incision, remove what is possible, remove pelvic organs if needed, and leave placenta if it is implanted on something vascular or vital. He agrees.

We start the case. I make a vertical incision, but we end up extending it more generously to the side of the umbilicus. It looks like there is blood beneath the peritoneum, and as we open it, old dark blood gushes out. We suction that up (no wonder her hemoglobin was so low – it was all in her abdomen). We can’t see much, so I reach my hand in. I feel a couple of globular structures in the pelvis that I can’t identify. Higher up, I feel fetal parts. I pull out the fetus. It’s dead, and looks about 17 weeks in size.

Then we see a gleaming white structure in the pelvis. “What is that?” we ask each other. We decide it’s uterus. I try to pull it up, but it seems stuck. Dr. W tries to pull it up, and it frees a bit and comes toward the surface. Suddenly, we realize it is placenta. Whoa. I realize that there is something around it – some kind of membrane or tissue. It’s uterus! Whoa. It’s hard to see, but it looks like the uterus probably ruptured posteriorly or in the fundus, and the placenta is coming through. Maybe she had an illegal abortion, and the person perforated the uterus? Whoa.

If the uterus is ruptured (and it seems like a big hole), we need to do a hysterectomy. I reach in to pull the whole uterus up, and I pull it out. To our surprise, the whole thing is placenta – it comes out, and one portion of it is still attached. We can see an intact uterus below it. Now we realize that the uterus is not ruptured or perforated – what we thought was uterine muscle was actually membrane and adnexal tissue on the right side. We delineate the attachment and realize that the placenta has implanted on the outer side of the adnexa (which is the ovary and the tube, plus the mesosalpinx, a membranous tissue attaches the two). WHOA.

I am still marveling over the insanity of this case when Dr. W breaks me out of my shock. “We are finished. We remove the whole thing, and we are done.” True. We can remove the entire adnexa. She will still have the ovary on the left side. If we detach the placenta but leave the adnexa, then the placental attachment site could bleed. After carefully assessing our location and surrounding structures, we clamp off the adnexa, cut and tie it so that it does bleed. Easy as pie.

Then we evaluate the other side. She wants a tubal ligation, so we could take just a piece of tube. But the tube has some adhesions and is already looking oozy. Taking just a piece could allow the rest of it to continue bleeding. We remove it, and leave only the ovary. The uterus is fine, and we leave it in place.

There is still a lot of blood in the abdomen. Dr. W seems ready to close, but I insist on suctioning it out, and irrigating. Blood in the abdomen can be very irritating, increase postoperative pain, and sometimes temporarily paralyze the gut so the patient has trouble eating for a few days. We get it all out, and I check all of our operative sites.

As we close, Dr. W lets me use the sutures and the technique I like. I insist on my subcuticular closure, and make jokes about how the incision is the only part that the patient sees. He laughs and agrees; he says he doesn’t mind doing the subcuticular.

After the procedure, I take the specimen to evaluate it. I still can’t figure out what happened. Where was the implantation? Was the pregnancy in the tube? It couldn’t have been – the fetus was floating in the upper abdomen, and a tubal pregnancy would never have grown that big. Did a tubal pregnancy rupture and then re-implant on the outside of the adnexa? Or did the pregnancy implant there from the beginning? I’m still not sure. I find an intact segment of tube, but not the fimbriated end. I also find the ovary, which is intact. The placenta seems to have implanted on the mesosalpinx, below the ovary. Most of it has abrupted off, but there is still a small portion attached. I have a medical student take pictures of the specimen while I display it so that the different elements are visible. Probably too gross for this blog, but pretty amazing.

The patient is in recovery now. She got 1 unit of blood in the OR, but she didn’t lose much. Most of what she lost was already in her abdomen. I write her for some pain medication, and I explain to her family what happened, and that she will be fine. She is a very, very lucky woman. That surgery could have been much worse, could have been fatal. I am incredibly relieved. I know I never would have forgiven myself if she had died on the table, even if I felt like I had no other option.

8 comments:

sarah jo said...

WHOA.

Paul said...

holy shit, Veronica. That is wild. I'm glad things turned out well. That whole post was crazy, but the whole doing a (potentially big) surgery with a hemoglobin of 5 blows my mind! Get yourself a book editor! (:

Doan Trung Hieu said...

Can you post the picture of the specimen, please?

Anonymous said...

Here the the uk 99.9% of doctors are idiots. I do not jest

Anonymous said...

I've had 4 csections, bad abdominal adhesions with each, last op, drs took an hour to get in to baby.
Im sure you get the picture.
So got my tubes tied with clips they said might come off as there was a lot of swelling, & a tummy tuck after my last child 7 years ago.
Last october i was a size 6 now my abdominal is huge & looks 8 months pregnant. Iv had 3 positive pregnancy tests rest negative including blood. I feel movement others have felt it. I did NOT want another child, hence the tubes being clipped!
No baby seen on scan , bloods are perfect, no tumours or cysts nothing to explain my huge pregnant looking & feeling tummy.
Also had a ligher cycle throughout. Ever watch " i didnt know i was pregnant?" This is the other side of it, they believed the doctors & tests i do not.
Why? I have a doppler & there is a fetal heart rate above 140 on it. Can also hear baby swimming & kicking the doppler! My dr says that doesnt prove a baby. Oh no? They used to use a stethoscope to diagnose a baby 50 years a go, dopplers use the same technology. Dah!
So iv brought a finger pulse im going to show my dr tomorrow, the doppler still says 140 plus , my finger pluse 80 or less! So it is NOT my heart beat its a baby! Not a phantom pregnancy as THERE IS A FETAL HEART BEAT! A person does not have two heart beats! Drs are so dim in th uk!

Anonymous said...

To continue , my doppler is 1hmz so picks up the baby as at low frq the ultrasound wave can penetrate dense scaring & bowel perhaps but my scans have all been 15 mhz or above. That's standard.
They need to adjust the frq as at high frqs nothing will be seen & baby is missed. I need an mri but since my dr does not think im pregnant she will not order one, despite my huge growing abdomen, dispite a large solid mass in my pelvis, that can only be felt from the side, as my small bowel seems to be in front of the baby & my muscles are sown tight from my tt.
Maybe its an abdominal pregnancy but i have had no pain & mild contractions plus a show over the last week.
Drs you do NOT know everything. You are not gods , sorry to brake it to you.
My child & i will probably die as most drs chose to believe in their technocratic fairy tale over common sense & basic logic.

Anonymous said...
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Jade Graham said...

get some ascorbic acid powder and mix it with a bit of water and rub it on the cancerous places on your ear. Eat lots of vitamin c, eat anything that will boost your immune system, pregnancy calendar