Atypical Ectopic Pregnancy

A 36-year-old lady, gravida 5, para 2 complained of a severe upper abdominal pain over the past day. The patient also reported acute diarrhea.

She had endured two miscarriages in the past along with an elective abortion. She did not have any sexually transmitted diseases. 

Her latest miscarriage had occurred 9 days before at eight weeks’ gestation. Her ultrasound at this time had shown no free fluid or adnexal masses. A complete abortion was confirmed. Vaginal bleeding stopped within a day or two; thereafter, she had no symptoms until the current painful episode.

On clinical examination, the lady was pale and afebrile. Her blood pressure was low – 94/59 mm of Hg. Her abdomen was soft with mild epigastric tenderness, and without lower abdominal tenderness and peritoneal signs. After 1 L of normal saline infusion her blood pressure increased to 110/88 mm Hg. The pain subsided without analgesics. 

However, after two hours, her abdominal pain became worse. At this stage, physical examination elicited a very tender upper abdomen without peritonitis. Her pregnancy test came positive. 

Through culdocentesis, a leaking ectopic pregnancy could be diagnosed. The patient also showed signs of imminent rupture. Aggressive fluid resuscitation, followed by an emergency laparotomy were conducted; a right salpingectomy was performed and a paratubal pregnancy and 1.5 L of blood were removed.

Postoperatively, the patient developed anemia and required blood transfusion. She eventually became stable after five days and was discharged. 

Culdocentesis is a useful procedure to ascertain intraperitoneal hemorrhage.