CASE REPORTS

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A CASE OF TUBAL ECTOPIC PREGNANCY

The possibility of ectopic pregnancy was explained to her and she was transported immediately to the nearby hospital as she could collapse as a result of haemoperitoneum. The patient underwent diagnostic laparoscopy the same evening. There was haemoperitonium and a leaking left tubal pregnancy at the ampullary region. Both ovaries and the right tube were normal. Left salphingectomy and peritoneal lavage was done laparoscopically and patient was discharged well the following evening.

DISCUSSION
Ectopic pregnancy cases are relatively uncommon in primary care. Although it comprises only 2% of all pregnancies,² the incidence has been on the rise.^2,3 It is associated with high mortality if diagnosis and management is delayed. Early intervention carries significantly better prognosis.⁴ Even surgery can be avoided if management starts before tubal rupture and cardiovascular compromise.1 Hence, it cannot be over emphasised that early diagnosis is of paramount importance.

As illustrated in this case, diagnosis can be easily missed in absence of classical symptoms of ectopic pregnancy compounded by incomplete patient assessment. The presentations of ectopic pregnancy vary from subtle abdominal pain to profound cardiovascular compromise. Common clinical presentations are as illustrated in Table1. Approximately 43-55% of ectopic pregnancies do not present with the classical triad of lower abdominal pain, period of amenorrhea and vaginal bleeding.^3,5 Early symptoms such as abdominal pain although the commonest, is not specific to ectopic pregancy6. About 9-30% of women may not have abdominal pain at presentation.^2,8 Differential diagnoses for abdominal pain in a young lady includes appendicitis, miscarriages, pelvic inflammatory disease and ovarian torsion.⁵ Absence of a period of amenorrhoea in ectopic pregnancy is rather common and occurs in about 25% of cases.^4,9 A detailed  menstrual history is important and any sudden change of menstrual pattern should alert the physician to think of the possibility of tubal ectopic pregnancy even in the absence of a clear period of amenorrhoea in women in the reproductive age group.

Table 1: Common clinical presentations of ectopic pregnancy^5,6,8,9

Signs and symptoms	Number (%)
Abdominal pain	90-97
Abdominal tenderness	87-91
Nausea or vomiting	80
Vaginal bleeding	79-83
Amenorrhea	75
Dizziness	55-60
Adnexal tenderness	54-57
Shoulder or neck or pleuritic pain	50
Cardiovascular compromise	50

This was a challenging case as the presentation was not the typical sequence of events. Absence of typical symptoms tends to mislead physicians from the possibility of an ectopic pregnancy. Hence, a high index of suspicion for this condition at the primary care level is emphasised. It also highlights the fact that the first episode of abnormal vaginal bleeding in a sexually active woman may be a clue to the underlying diagnosis of ectopic pregnancy and should not be dismissed as dysfunctional uterine bleeding.

REFERENCES

1. Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of  ectopic  pregnancy. CMAJ. 2005 Oct 11;173(8):905-12 [PubMed] [Full text]
2. Tay JI, Moore J, Walker JJ. Ectopic pregnancy. BMJ. 2000 Apr 1;320(7239):916-9 [PubMed] [Full text]
3. Dialani V, Levine D. Ectopic pregnancy: a review. Ultrasound Q.  2004 Sep;20(3):105-17 [PubMed]
4. Cunningham FG, MacDonald PC, Gant NF, Gilstrap LC, Leveno K, editors. Williams Obstetrics: ectopic pregnancy. 19th ed. East Norwalk (CN): Appleton & Lange; 1993. p. 691-720
5. Wong E, Suat SO. Ectopic pregnancy: a diagnostic challenge in the emergency department. Eur J Emerg Med. 2000 Sep;7(3):189-94 [PubMed]
6. Aboud E, Chaliha C. Nine year survey of 138 ectopic pregnancies. Arch Gynecol Obstet. 1998;261(2):83-7 [PubMed]
7. Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005 Nov 1;72(9):1707-14 [PubMed] [Full text]
8. Aboud E. A 5 year review of ectopic pregnancy. Clin Exp Obstet Gynecol. 1997;24(3):127-9 [PubMed]
9. Thomas LS. Ectopic pregnancy. Top Emerg Med. 2002;24(4):12-20 [Link]

Address for correspondence: Dr Leelavathi Muthupalaniappen, Lecturer, Department of Family Medicine, Faculty of Medicine, Kompleks Pendidikan Perubatan Canselor Tuanku Jaffar, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Kuala Lumpur. Tel 03-91733333, Fax 03-91738153, drleela@mail.hukm.ukm.my

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