Case Presentation
A 36-year-old Black woman with three prior full-term pregnancies and three births, two of whom are living and one child lost at age two, presented with a history of irregular menstrual cycles for the past two months. She reported sudden, intense abdominal pain, vomiting, and generalized weakness. Moreover, she was feeling extremely tired, experiencing headaches, and noticing occasional vaginal bleeding.
Typically, she has a 28-day menstrual cycle, bleeding for three days and using two to three pads a day due to moderate soaking. However, she observed changes in her menstrual flow over the last two cycles. In August, her period lasted only a day, requiring just one pad. In September, it lasted two days, also with just one pad used. She mentioned no previous experiences of painful menstruation, irregular bleeding between periods, or pain during sexual intercourse. Additionally, she had no history of ectopic pregnancy and had never been treated for sexually transmitted infections or pelvic inflammatory disease. She had never undergone surgery or been diagnosed with a chronic illness. Her method of contraception was the calendar method. She didn’t smoke but did drink alcohol occasionally.
Investigations
Upon her arrival at our hospital, she was fully conscious but in a position suggesting she was in pain. Her vital signs indicated she was in shock, with a blood pressure of 80/50 mmHg and a rapid pulse of 138 beats per minute. Her skin was pale, her abdomen was swollen, and she showed signs of irritation in the abdominal cavity. An examination with a vaginal speculum showed light bleeding from the cervical opening. This led to an initial assessment of acute abdominal distress. Doctors immediately set up two large intravenous lines and collected blood samples for various tests, including pregnancy, hemoglobin level, and blood typing. After administering fluids intravenously, they found her pregnancy test to be positive. Her hemoglobin was low at 7.7 g/dL, suggesting a ruptured ectopic pregnancy as a probable diagnosis.
Due to the urgency and lack of available ultrasound equipment, doctors couldn’t send her for further imaging. They urgently called in our surgical and anesthesia teams to prepare for emergency surgery.
Management
During the operation, surgeons found a significant amount of blood in her abdominal cavity. They discovered a fetus weighing 500 grams and a placenta weighing 800 grams near the left upper part of the uterus, showing no signs of life or decomposition. The rupture had occurred in the upper left part of the fallopian tube. When they injected a solution into the cervical opening, it flowed out of the fallopian tubes without indicating any connection to the rupture, showing that the tubes themselves were otherwise normal and not inflamed. They repaired the rupture site, thoroughly cleaned the abdomen, and flushed it with a warm saline solution before closing up. The estimated blood loss was about 2.5 liters.
This case highlights the critical nature of recognizing and acting swiftly on the signs of ectopic pregnancy to prevent life-threatening complications.
Post-operative Care
During her surgery, the patient was given two units of whole blood and two liters of crystalloids. Despite the surgery being conducted under sterile conditions, she was started on IV antibiotics, painkillers, and fluids. She didn’t eat for 24 hours. On the first and second days after the operation, she received an additional two units of whole blood. Her recovery in the ward was positive, with her symptoms improving and her vital signs stabilizing by the first day. By the second day, she was up and walking, and we switched her to oral antibiotics and pain medication. Her hemoglobin level rose to 8.7 g/dL by the third day, and we prescribed oral iron and folic acid.
She left the hospital on the seventh-day post-surgery, after we provided education on menstrual health, family planning advice, and a discussion on the risks for future pregnancies. A follow-up appointment was scheduled for six weeks later.
Ectopic Pregnancy
Ectopic pregnancies, which occur in about 1-2% of all pregnancies, are responsible for 6-9% of pregnancy-related fatalities, making them the primary cause of death in the first trimester. Among these, non-tubal ectopic pregnancies, including those in the interstitial part of the fallopian tubes, are uncommon, constituting 5-10% of all ectopic cases. Specifically, interstitial pregnancies, which are found in the portion of the tube that passes through the uterine muscle, make up 1–11% of ectopic pregnancies.
These can develop up to the early second trimester. They are often diagnosed later than other types due to the muscular layer of the uterus allowing more room for growth. This sometimes leads to larger fetal sizes before detection. Unlike other ectopic pregnancies, interstitial ones often come to medical attention due to rupture or the threat of it. This was complicated by the fact that diagnosis is challenging both clinically and with imaging. Symptoms like abdominal pain, light vaginal spotting, nausea, dizziness, and weakness are common. Their intensity varies based on the state of rupture, bleeding amount, and the patient’s overall blood circulation health.
Ultrasonography is pivotal for diagnosis. Finding an empty uterus and signs like an interstitial line or sac strongly suggest an interstitial ectopic pregnancy. However, many such pregnancies are only identified as ruptured ectopic cases during surgical intervention. Risk factors mirror those of other ectopic pregnancies, including a history of pelvic inflammatory disease, fertility treatments, smoking, certain contraceptives, and previous ectopic pregnancies. Treatment may be conservative, medical, or surgical. This depends on factors such as the size of the embryo, the presentation and levels of B-HCG, and ultrasound findings. Moreover, the patient’s circulation status, and how the condition evolves. Given that many women are in a state of emergency with rupture or near-rupture and circulatory instability, surgical intervention is often necessary.
Conclusion: Ectopic Pregnancy
Cases of interstitial ectopic pregnancy reaching or surpassing 20 weeks of gestation are exceedingly rare. This report details an unusual case of an advanced interstitial ectopic pregnancy identified during emergency surgery for a suspected rupture in a 36-year-old woman experiencing severe circulatory instability.
