Sunday, May 30, 2010

Land of ectopics

When I was in residency, the diagnosis of an ectopic pregnancy (a pregnancy that is outside of the uterus) entered my differential in only a handful of patients that I saw. I think I only saw 1 or 2 patients at the most with an ectopic pregnancy. That sure changed when I got to PNG. PNG is a place where polygamy is accepted and as a result we treat a lot of sexually transmitted diseases. For guys, this usually doesn't result in significant sequelae, but for women it is a different story. As a result of the STD, the women are at risk for something called PID - pelvic inflammatory disease (among other things), which is inflammation of the women's pelvic organs, including their fallopian tubes. This often results in scarring of the fallopian tubes which can result in a blocked tube the causes the little baby to get stuck and can't get into the uterus. The baby keeps growing, but the tube can only expand so far before it ruptures. When it ruptures the women typically starts bleeding inside and unless she is taken to a hospital soon and someone opens up her belly she can bleed to death and die.
I don't know how many ectopics I have seen here, but any women of child bearing age is at risk, and it has to come into the differential, whether their history fits or not. A typical history is a women who hasn't had a kid despite being married for a number of years, has missed her period for 2 months, has some lower abdominal pain and bleeding. If everyone fit into this history, it would be easy to find them. Our patients usually don't fit that pattern so we have to keep the dx of ectopic pregnancy in the differential no matter what the history is. Recently, I had a women who reported normal periods, has a 4 yo child, and denied being with anyone recently. She was anemic with a hgb of 5 with a belly full of fluid and a positive pregnancy test - despite her history, she was had a ruptured ectopic.
The other day was a record day though. I diagnosed 3 ectopic pregnancies in one day with the help of our ultrasound machine. Our ultrasound machine is one of the best purchases we made (thanks to all of those who contributed and made the purchase of the machine possible.) I didn't know a thing about doing ultrasounds prior to coming here, but now after doing over 1000, I feel like I have a pretty good idea of what I am looking at. Each of the 3 ectopics was a little different. One was ruptured (her belly was full of blood), one was unruptured (baby still inside the tube and no fluid in her abdomen), and one was a heterotopic (a baby inside the uterus and one outside the uterus which had ruptured). Unfortunately our surgeon, Jim, wasn't here, so they were all transferred to Hagen for their surgeries, a busy day for Hagen.