Sunday, February 7, 2010

Frozen Pelvis

It has been a long time since I have done much Gyn surgery. I have done a bunch of cesareans since residency, but not much else. I had been nervous about how quickly I would jump back into it, but a recent challenge put some of my fears to rest.

A generalist physician I greatly respect here in Tororo asked me to review a patient on Female Ward. The patient had marked abdominopelvic tenderness, but no discernible pelvic mass. An ultrasound at TDH had reported an ectopic pregnancy, but he didn't trust that sonographer and wanted me to evaluate her.

I brought my portable ultrasound to the ward, accompanied by L., a Family Medicine Resident recently arrived from Madison, Wisconsin. I spoke to the patient, who thankfully spoke English, and got a history. She was 24, and had one prior pregnancy that resulted in an early miscarriage. Her period was sometime in November, which would put her between 9 and 12 weeks of pregnancy. Back in early January, she started having light spotting, and the next day pain. The pain was most severe on the second day, when she went to a clinic in Kampala, where she was told they had to "remove the pregnancy." It sounded like they did a D&C, but nothing else. Since then, she has had pain and light spotting.

I started scanning her and immediately I saw an empty uterus. To the right of the uterus there was what I can only describe as a huge bunch of crap. It was about 8 cm by 4 cm, and was probably a whole bunch of clotted blood. The right side of her lower abdomen was also remarkably tender. I looked at her left ovary and found it easily, looking quite normal.

The most likely diagnosis is an old ruptured ectopic pregnancy. I didn't see any free fluid, which is how liquid blood would look. The size of the mass meant that it was unlikely to be just an ectopic - but one surrounded by clotted blood could easily be that big. Although sometimes ectopic pregnancies can resolve on their own, there is no way to predict that. They are so often deadly, and one that bled before could still be bleeding or could bleed again. When an ectopic pregnancy is diagnosed, action must be taken.

In the US, if an ectopic pregnancy looks intact (not ruptured), it can be treated with an injection of methotrexate - a chemotherapeutic agent that is toxic to the pregnancy. It allows that abnormally located pregnancy to detatch from the tube, ideally without bleeding much. The advantage to this method is that it spares the tubes, and avoids surgery. An ectopic pregnancy that may be ruptured or has other contraindications to methotrexate can be managed with a laparoscopic surgery - using a tiny camera inserted in the umbilicus, and two other instruments inseted through tiny holes. Recovery is quick, and sometimes patients even go home the same day. Here, neither is an option. Ectopic pregnancies must be managed with a laparotomy - a larger incision on the abdomen. So, this was the plan.

We notified the theatre, and I dashed over to Labor Ward and Antenatal clinic to see a few patients waiting for me. I was finishing up when I got the call that the theatre was ready. Sweating in the 95 degree heat, I grabbed my scrubs and bought 2 hard-boiled eggs for lunch (the only quick food available here, 25 cents for 2) and dashed to the theatre, peeling eggs on my way.

I tried opening a mini-laparotomy, a smaller incision about 4-5cm, hoping to complete the surgery with minimal skin trauma - which didn't work. The surgery was incredibly difficult at every stage. Getting into the abdomen was tough. As soon as I managed to open the peritoneum, I should have seen a nice small uterus, two tubes and two ovaries (with ectopics, sometimes you have to clear out the blood first, but the anatomy is consistent). In this case, I couldn’t see anything. What on earth WAS that? I tried to feel, but couldn’t get my hand in. I expanded the incision more than once, until it was the size of a large cesarean incision. I could put my hand it, but couldn’t see or feel anything recognizable.

Was that clot? Or bowel? Or clot adherent to bowel? I stuck my hand in to palpate the organs, and felt very little. Lots of stuck crud. Where was the uterus? For that matter, where was the tube or ovary? Bowel, bowel, bowel, and crud. How. The. Hell. Am. I. Going. To. Do. ANYTHING.

The situation was what we refer to as a "frozen pelvis." It means that the adhesions (scarring) inside the abdomen are so abundant and dense that every organ in the pelvis is essentially stuck in place. They don't move much, and any attempt to enter results in tearing of adhesions off of the surface of organs - which can cause damage to the organs.

I didn't want to touch the bowel in any way. It was so stuck, and if I tore it, there would be no General Surgery consult to come and repair it for me. It would be a horror show. And for that matter, where was the bladder?

I heard the voice of my former MFM fellow from residency explaining to me how he got through a really difficult cesarean section: "You just have to establish normal anatomy, right?" Right. OK. I saw something that looked like maybe the right tube. Then I found the front of the uterus. Both the “tube” and the uterus were completely stuck from behind – probably to bowel.

I wanted to confirm that the structure I thought was tube was actually tube. I asked for different kinds of instruments - better for grabbing tissue. Shockingly, I got them! After using multiple laps to wipe up the blood, I commented to L that I would give my kingdom for a suction. "Suction?" the anesthetist said, and walked out of the room, returning with.......suction! What a revelation!

(Toward the end of the case, I muttered, "This is where I would really love to have cautery." And the anesthetist said "Cautery? We have, but you didn't ask for it, so it is not set up. Next time." A bovie?!? That works??! Who knew? Next time, I'm going to ask. Any chance of a laparoscope?)

I was finally able to identify the tube definitively by finding the fibmbriated end. I also found the pelvic sidewall, the round ligament and the infundibulopelvic ligament. I kept searching for ovary, and finally found a glimmer of white where the ovary should be. It was either ovary or organized clot. "What does it feel like?" asked L. "Crud," I said.
Nonetheless, I got some sense of the surrounding pelvic structures. Unfortunately, the posterior surface of the tube was densely adherent to something, and I wouldn't be able to get to it. How could I possibly remove her damaged tube and her ectopic pregnancy when I can't even see the whole tube?

I saw a hole starting to form in the thin surface of the tube. I had an idea: cut the tube open, identify the parts of it better, remove what I can, and stop the bleeding. Anyway, I had no better ideas.

I did it, and it actually worked. I cut out the free edges of the tube, stitched, and the bleeding stopped. Phew! OK, should I do more? Most of the tube was still left, so she could easily have another ectopic pregnancy. But trying to dissect out more would run the risk of damaging bowel - not worth the risk.

At this point, the theatre was HOT. There is no air-conditioning, and there is one functional but irrelevant fan. It was 95 degrees that day in Tororo, and in the OR it felt like 110. We were already drenched with sweat. Still, we pressed on. We evaluated the abdomen carefully for bleeding. I got some saline for irrigation, and looked for bleeders. Nothing. Phew.

Closing the fascia, we had to pause once to check for bleeding, but it was ok. I got to the skin, and started my subcuticular closure. The needle became damaged, and eventually had to be replaced. Ugh. I started really sweating, and getting so dizzy. I had been sick with strep throat for about 2 weeks, and this was the first day I had finally felt better. Now I was beyond dehydrated, and feeling it. I kept going. I paused for deep breaths occasionally. My scrubs were drenched, I felt sweat dripping all over. I kept stitching, and started complaining (it helps me get through). L was sympathetic, and very patient. I'm sure she was dying for me to finish. As I complained, the anesthetist said "Why don't you just do the big stitches we do?" Meaning those huge nasty things right through the skin. No way - I had to finish this.

I pulled it together, using all my energy to focus on stitching, and in the end the repair was quite nice. Afterward, L and I raced to the clinic, plopped chairs in front of the water cooler, and downed countless cups of water. She was a real trooper through the whole thing - not one complaint. We checked the time, and realized we'd been in the OR two and a half hours.

Sadly, I really doubt this girl will ever get pregnant. Her left tube is probably as bad as her right, and I couldn't even find it. If she does get pregnant, I hope it's not an ectopic, because I don't know how they will find it. If it is a normal pregnancy, I hope she doesn't need a cesarean.

The question is, why was this case so bad? I’ve done my share of bad ectopics at home – with 3 liters of blood in the belly, huge clots, weirdly positioned ectopics, unstable patients. But none of the operations came close to being as difficult as this one. The only cases I've seen that were this bad were Gyn Oncology patients - with bad cancer. But in those cases, I was operating with an experienced Gyn Oncology attending and fellow, so I had plenty of guidance.

In this case, the ectopic probably ruptured 3 weeks ago, when she had the futile D&C. She likely bled into her abdomen, and then the clot that formed created a tamponade that prevented additional bleeding from the tube. Most women just bleed to death at that point. She is lucky to be alive. But all the blood in her abdomen gave her the continuing pain. Eventually the blood clot became organized – looking more whitish and dense, hard to differentiate from normal tissue. This was part of the difficulty in the OR – I couldn’t tell if it was bowel or clot. But also, the inflammation from the blood created scarring in the abdomen, which caused her bowels to stick to everything. Three weeks later, the scarring had solidified into a frozen pelvis.

In the US, women with ruptured ectopics come to the hospital, get an ultrasound, and get the appropriate treatment. If the diagnosis is missed at first (it can be confusing), it is caught within 1 or 2 days. We can check BHCG, do transvaginal ultrasonography and laparoscopy. When her D&C showed no products of conception, we would have immediately done a laparoscopy. But here, that’s not the case. I have never seen an ectopic this bad because almost no one would be sent away in her condition. We just don’t see people coming in who have had large amounts of blood in their abdomen for 3 weeks.

It was such a tough case, and I am pleased that I was able to get through it, although I watched her nervously for several days. I talked it over with some doctors here, and they all agree that these cases are really rough. I'm glad I didn't cause any major injuries. At home, we would follow her BHCG (blood pregnancy level) to make sure the ectopic pregnancy is really gone, since I didn't take her whole tube. Here, we can't do that. Over several postoperative days, she was gradually able to control her pain, get out of bed and eat - these are all good signs. She went home recently, and I am keeping my fingers crossed for her. Most of all, I hope she never needs another surgery.

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