Wednesday, February 17, 2010

Where is the Pregnancy?

One of the study doctors says to me “There is a mother here I would like you to see. I have told her to wait for you.”

The “mother” is the mother of a child in one of our pediatric studies. According to the study doctor, she had complaints of pain with bleeding, and another of our study doctors had given her some antibiotics (a common theme – antibiotics are like candy here) but she didn’t improve, so they thought she should see me, and that perhaps I should do an ultrasound. No other details are known.

We invite the woman into the room, and although she speaks some English, she doesn’t feel it is strong enough, so the study doctor translates for me.

I ask for a description of the problem.
Her period started two weeks ago, and hasn’t stopped. She is also having a lot of pain, and she doesn’t usually have pain with her periods, so she was concerned.

When was her last period?
She isn’t sure, but they are regular and she hasn’t missed one.

So she had one last month?
Yes, she did.

In which part of the month do her periods usually come?
Toward the end of the month.

So the period that came two weeks ago was at the right time?
Yes, it was, but it hasn’t stopped.

Is she using family planning?
No, she isn’t.

Is she pregnant?
No, she isn’t. She hasn’t missed a period.

When was her last child born?
Two years ago.

Is the bleeding heavy?
No, it is light. Lighter than a usual period, in fact.

Is the pain strong? Which side?
Yes it is strong, but she is able to do her usual activities. It is in the middle.

I decide to do an ultrasound, but while I am getting the machine, I ask the patient to give a urine sample for a pregnancy test.

When I return with the ultrasound machine, the study doctor says, “Her urine pregnancy test is positive.”


“She is surprised, because she doesn’t think she missed a period.”

Lesson number one that all Ob/Gyn interns learn: Always get a pregnancy test.

I palpate her abdomen. She is mildly tender in the center of her lower abdomen, but it is not very impressive. The bleeding could suggest that she is having a miscarriage. But it could also be present in case of an ectopic pregnancy. The classic teaching is that if the bleeding is out of proportion to the pain, then be highly suspicious for ectopic.

I start the ultrasound. Right away, I see her uterus. The uterine lining is thin, and there is no blood or pregnancy inside. Ding. I look around the uterus, and immediately I see a thick-walled circular structure just behind (posterior to) the uterus. Ding. I evaluate the structure more closely, and inside I see a very small yolk sac – the earliest stage of pregnancy development that is visible on ultrasound. Dingdingding. Ectopic pregnancy.

I scan further, and the ectopic seems to be more toward the right side than the left, although it is not certain. Toward the left side, I see a normal ovary, but toward the right, I see only the ectopic. It is usually hard to visualize tubes on ultrasound, but around 98% of ectopic pregnancies are in the tube, so if you see a mass in the adnexa, it is usually a tubal pregnancy.

She needs to go to theatre, but it is after 5 and they will never take her at this hour. She is quite stable, and there is no evidence that the ectopic is ruptured or leaking. I explain the need for surgery, and I offer to let her stay overnight, or come back in the morning. She needs to care for her children, so she will come back in the morning. I call the anesthetist and we agree to do the case at 10am. I tell her to come at 8am. I give her the ultrasound report, and write our plans for surgery, and instructions to admit her to Female Surgical Ward tomorrow. I also write my phone number at the bottom, just in case.

The next day, between 9 and 10, I am looking for the patient. I have been told that she came to clinic looking for me, but left. I go to the Female Surgical Ward, but she is not admitted there. I find her sitting outside, and she says that no one has admitted her yet. I help get her admitted and we discuss the consent. Yesterday, I had told her that one of her tubes probably contained the ectopic and would have to be removed, and I asked if she wants more children (she had 5, but only 3 are living). She said “I am old!” and laughed (she is 34). She stated clearly that she doesn’t want more children and that she wants both tubes cut. Today, she is here with her husband. (In Uganda, usually both the husband and the patient need to consent for a tubal ligation. When I told the midwives that in the US, only the patient needs to consent, one of them said “That is because in America, you are advanced!”) I speak with her and the husband together, and both very clearly agree to cut the tubes.

L, the family medicine resident from the previous case, has agreed to assist me in this one as well. Once the patient is asleep, we make a small incision on her abdomen called a mini-laparotomy. There is just a little blood inside, which actually might be from our incision, it’s hard to tell. I spot her small, normal uterus right away. This is what the other patient was supposed to look like. I follow it to the right, and grasp the right tube with a gentle instrument, looking for the ectopic. I reach the fimbriated end of the tube – no ectopic. Hmm. The ectopic must have been in the left tube,

I drop the right tube and go back to the uterus, following it to the left to find the left tube. I grasp it and pull it up – and again I reach the fimbriated end, but no ectopic. What?? Where is the pregnancy? I can see her left ovary just next to the tube, and it is completely normal. So now there are three options – either the ectopic pregnancy is on her right ovary (ovarian ectopic – very rare), or it is in her abdomen (abdominal ectopic, exceedingly rare but fascinating when it happens), or I was wrong altogether and there’s no ectopic. I think hard about the third possibility – certainly I’m not infallible, but that ultrasound was strongly suggestive of an ectopic. And I saw her uterus very clearly – there was no ambiguity. Still, I would feel terrible if I took her to the OR for no reason.

I go back toward the right side and pull up the tube again. I feel a little resistance to pulling it any higher, and I can’t see the ovary. I put my hand in behind it to free the posterior aspect, and feel some clotted blood. Then I free the ovary and pull it up – and lo and behold, one side of the ovary is covered in ugly ectopic pregnancy and clotted blood. An ovarian ectopic!

I had always heard about these in residency as a theoretical possibility, but I had never seen one. They are problematic, because you can remove a tube easily, but ovaries are needed for hormonal maintenance in premenopaual women. A woman who loses one ovary is usually fine and can be hormonally normal with just one ovary, but still it’s a shame to take out an ovary in a young woman. Ovaries bleed more than tubes – they are highly vascular. They are also very hard to stitch – the tissue is mushy because it’s mostly just ovulatory tissue. So often when you start mucking around with an ovary, you end up needing to remove it just to stop the bleeding.

First, I clear the pregnancy off the surface of the ovary. It is mushy and dark grey. I know I have removed it all when I have only white, smooth tissue left. Unfortunately, that white soft tissue is bleeding, and half the ovary’s capsule is gone with the pregnancy, so I can’t use it to stitch. I tell L, “I’ll try to throw some stitches to stop the bleeding, but if I can’t, we’ll have to remove the ovary.” At this point, the anesthetist and theatre nurse are fascinating. “That’s the ovary?” they ask me several times. They also register my excitement over the fact that the pregnancy is in the ovary itself.

I recently rearranged the entire suture closet for the OR. I really don’t like chromic suture, but it’s all that people use here. I would occasionally find Vicryl – my personal favorite – but the closet was a mess and it was hard to find what I needed. So I spent an hour one day sorting the suture by type – absorbable, non-absorbable, size, type, etc. And I put everything in neat stacks with the non-absorbable suture (like silk and nylon) in the back, because I never need it. I also figured out which generic sutures are similar to Vicryl and Monocryl. My organizational work really paid off, because now I am able to pull out the sutures I want before each case, and I don’t have to use chromic.

For this case, I pulled out a 4-0 Monocryl, intending to use it on the skin. But now I clearly need it for the ovary. Sutures are named for their size and their type. Monocryl is a single-strand synthetic absorbable suture material, whereas Vicryl is a braided synthetic absorbable suture material. There is also chromic, which is catgut (from animals, but not necessarily cats), very versatile but stiff and very slippery. Some people love it; I don’t. Vicryl is strong and is nice to work with because it feels like thread, and isn’t as slippery when wet. Monocryl feels more plastic-y and slippery, but dissolves nicely under the skin and causes very little friction on friable surfaces – like ovaries. The numbering system tells you the size. If the number is written as 1-0, 2-0, 3-0, then the size of the thread gets smaller as the number gets higher. If the number is written as 1, 2, 3, then the thread gets bigger as the number gets higher. so a 4-0 vicryl would be a very small suture, and a 2-vicryl would be a thick suture. A 0-vicryl, which we often use in cesareans, is in the middle, good for stitching uterus and fascia. Plastic surgeons will use sutures as small as 6-0, and once I even saw a 9-0 in the suture closet, which must be practically invisible.

I request the Monocryl, and throw some very, very careful stitches across the bleeding surface of the ovary. Although I have never done an ovarian ectopic, I have discussed it many times in residency as a what-if. In addition, I have been in surgeries – mostly hysterectomies or ovarian cystectomies - in which scarring around the ovaries caused some bleeding, and required delicate repair. From these experiences, I adapt what I know to create stitches that will hopefully stop the bleeding without damaging the ovary too much. To my surprise, it stops bleeding. I tie (and cut) the tubes easily as I had been taught in residency. Then I look back at the ovary, and it is not bleeding. Wow! I am very excited.

We close the incision with another 4-0 monocryl. When we bring the patient back to the ward, I tell the family about the ovarian ectopic and that we tied the tubes, but I’m not sure they understand. The next day, she is looking well, but hasn’t walked or eaten yet. I give her permission to do both. The second postop day, late morning, I go to see her, and she has already been discharged. She had been looking so well that the nurses sent her home. I know she is a mother in our studies, so she will come back.

Today, I am in the clinic when one of the study doctors tells me she is here and wants to see me. I find her in the waiting area. Her English is better than she had let on – the first thing she says is “When will you take out the stitches?” I tell her I won’t – they will dissolve. She smiles broadly and exclaims “Eh!” Most doctors here make huge vertical incisions and use non-absorbable suture to close the wound, which then needs to be removed after 7 days. It’s a painful process and leave scars and ugly keloids. Instead, my subcuticular closure is pretty and heals into a miniscule line. I have been getting many jokes from the midwives about my pretty incisions (and about how they don’t get infected like the big ugly ones).

I bring her inside to examine her. She is still wearing the original bandage. I remove it, and the scar looks great. I have someone explain in her language that there is no need for suture removal, and she is thrilled all over again. I ask how she is doing. The pain is very little, and she is doing well. She is glad she doesn’t have to worry about pregnancy anymore, and her husband is happy about the tubal ligation as well. She thanks me with a warm Ugandan handshake.

Later, she pulls me aside in the hallway, and shows me the original ultrasound report that I had written for her, with my orders for admission and my phone number. She points at the phone number and says (in English) “I want you to give me this one. So that I can call you if I have problems.” I ask her why she can’t keep the form. “Who is keeping this form?” She says she doesn’t know.

In the US, I never gave out my phone or pager number. Here, patients have limited access to a phone, so if they call you, it’s because they really need something. In fact, I’ve never gotten a call from someone at home. Some patients have gotten my number off the sign in Labor Ward and called me with questions while in labor, but they never called me from home after that. And I have given my number to some postop patients, or Antenatal clinic patients, and not one has called me. I am happy to give it out here to the ones who really need it, because I want to do anything I can to increase their access to care.

“The form is yours,” I say. Keep it, and my phone number is there. You can call me if you need.” We shake hands again, and both walk away happy.

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