Wednesday, December 7, 2016

Young female patient? Could be an ectopic pregnancy!!!!

Young female came with lower abdominal pain for 3 days. She gave a history of mild per vaginal bleeding few days back. She had no history of fever but had some vague symptoms suggestive of urinary tract infections. However she was afebrile. No abdominal tenderness on examination. However her urine pregnancy test/ HCG was positive. She underwent an ultrasound scan which revealed NO intra-uterine pregnancy. However no free fluid in abdominal cavity!!!

Next day also she underwent an ultrasound scan & came the same results. Her CRP (inflammatory marker) came as 22 (<5- normal) which is little high.

Mind you that unlike in developed countries, serum level of beta-HCG is not freely available at peripheral hospitals in our country. In addition it is costly & poor people usually cannot afford. So she was managed as completed miscarriage or urinary tract infection. She was not started on antibiotics as she was allergic to many drugs.

By the time she was seen by me, urine full report was not available. Apparently the sample was misplaced or something has happened. She was insisting on going home as she felt much better & for something in her job.

Now already 2 scans have been normal. But CRP was high. No urine full report. No way to get done serum beta HCG. Junior doctor who saw in the morning too suggested me to send her with antibiotics. However I was not happy to send her home as I had no proper diagnosis.  Although the patient & her family members insisted, I decided to keep her in the ward till everything is clear.

So the patient stayed in the ward & at the middle of the same day night, she developed a severe pain & when scanned again there were free fluid in the abdomen !!!
Immediately she was taken to the operation theatre & laparotomy was done. It was a leaking tubal ectopic with nearly 600 ml of blood inside the abdominal cavity !!!

Surgery was successful & her recovery was uneventful.

We all make mistakes. Sometime lack of facilities may lead you through a wrong diagnosis. Had I sent this patient home with antibiotics, concerning her job & future in a humanitarian view, she would have died during her job interview !!

Lesson. - In a female patient with abdominal pain, unless proven otherwise it is ALWAYS an ectopic pregnancy.

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