O&G: Ruptured ectopic pregnancy with u/l heterotrophic pregnancy

My first case here would be a ruptured ectopic pregnancy with underlying heterotrophic pregnancy.

I was called to OT yesterday as I was the EMOT Houseman of the day. I was quite unhappy when I was informed about the case because nobody from antenatal or gynae ward informed me to get ready beforehand. When I reached the OT, only I knew that the case wasn't from the ward but from the emergency department, it was a case of ruptured ectopic pregnancy.

Patient is a middle age lady, with history of complete miscarriage about 3 weeks ago, presented to ETD with lower abdominal pain and anaemic symptoms complicated with shock. The BP was low and requiring inotropic support. Initially case referred to surgical team to rule out acute abdomen, CXR no air under diaphragm, AXR no dilated bowels, bedside scan noted some free fluid at Morrison pouch. They also ordered for amylase to rule out pancreatitis. The initial walking diagnosis was septic shock secondary to intraabdominal sepsis.

Case then referred to gynae, where they found that the UPT remained positive albeit the complete miscarriage was weeks ago. Also, repeated bedside abdominal scan showed organised clots at pouch of Douglas with free fluid up to Morrison pouch, thus diagnosed as ruptured ectopic pregnancy. An emergency laparotomy with salpingectomy need to be done to look for active bleeding.

Case was posted urgently and need to be done in COVID OT because the COVID PCR status of patient was pending. 2 pints packed cells was requested from blood bank because we were anticipating massive blood loss on the table. 

It was my first time entering COVID OT, where I need to fully don in with full PPE. The face shield was very disturbing because it refracts the light. As the operation went on, the face shield kept on obstructing my view because of the build up of water vapour on it. 

When surgeon cut into the intraabdominal cavity, large amount of blood clots came out. It looks like the dark colour jelly bean curd sold in ZenQ haha. We had to quickly evacuate the blood clot as it obscure the view in the intrabdominal cavity where the surgeon needs to find the bleeding point asap.

Large amount of blood clots in the intraabdominal cavity also means that the bleeding is massive and its been quite some time. At the same time blood was continuously oozing out from nowhere and therefore we have to work as fast as we can to  look for the bleeding point. At last the ruptured tubal ectopic pregnancy with a size of 4x3cm was found at the right fallopian tube while the left side was completely normal. The right fallopian tube was then ligated and salpingectomy done.

The blood clots filled up the entire kidney dish, the estimated blood loss was about 1.2L, which my MO said it was still okay for a case of ruptured ectopic pregnancy. Then the operation was completed uneventfully.

The peculiar thing in this case is the patient is having an ectopic pregnancy while also had a complete miscarriage 3 weeks ago. My MO explained that this is likely a heterotrophic pregnancy, where intra and extrauterine pregnancy happened at the same time, which is extremely rare. Looking at the size of the embryo from the ectopic pregnancy, it is unlikely that this ectopic pregnancy happened immediately after the complete miscarriage.

This is my first time encountering ruptured ectopic pregnancy. We always read on textbook and know it was an emergency case, but never see in real life. It is obviously life-threatening and requiring immediate act as seen in this case. Patient was anaemic and in shock, if we don't act fast enough, patient might die of hypovolaemic shock in short time.

That's all for this case. Thanks for reading.