A positive test later, we knew it was on. I began looking forward to a 9 month journey of constant reassuring and waiting and weight gain and other amazing body changes. My hopes were threatened by a sudden announcement of vaginal bleeding. Oh my! What could this possibly be? Fortunately, her genital exam was reassuring, but since playing safe always paid off, I asked for a pelvic ultrasound anyway. And to our greatest surprise, we found an ectopic pregnancy!!!
I knew the deadly implications associated with the diagnosis so nonchalance was certainly no way to go about this. At first, I wasn't sure what to do. First case ever, and even though I still had vague recollections of my med school notes I wasn't about to gamble on someone's life (knowing the other's was already condemned). I did remember that nonsurgical treatment was possible if caught early enough. I called up an OB/GYN and we briefly discussed my patient. But at the end, the decision-making was still left up to me: to operate or give methotrexate. That's when I turned to Fernandez's score, a clinical predictive tool to aid management decision making of an ectopic pregnancy.
Predictive score for successful treatment of ectopic pregnancy
Predictive score for expectant management and several nonsurgical treatments (Fernandez 1991)
CRITERION 1 POINT 2 POINTS 3 POINTS
β-hCG (mIU/mL) <1000 1000–5000 >5000
Progesterone (ng/mL) <5 5–10 >10
Abdominal pain Absent Induced Spontaneous
Hematosalpinx (cm) <1 1–3 >3
Hemoperitoneum (mL) 0 1–100 >100
Score <12: 80% success with various nonsurgical treatments, including expectant management.
Predictive score for single dose methotrexate aka nonsurgical treatment (Elito 1999)*
A quick look at that table and I began dreading the worse. Her numbers weren't looking good and due to her financial situation, I truly wanted to help but surgery was probably the best option at this point. I was still considering a trial of methotrexate, the drug that would interrupt the pregnancy nonsurgically when my friend barged into my office. She was in pain!!! Unremitting and excruciating pain!!! It took two injections of tramadol for me to realize that I had to abandon all I was doing and find the surgeon. Butterfly effect; 30 minutes later, we were in full mode operation for ruptured ectopic pregnancy and a life-threatening generalised abdominal contamination (peritonitis) caused by the bleeding. Immediate clean up was required for patient survival.
 |
| our tiny embryo :( |
We tried removing the embryo alone, but the whole fallopian tube had to follow because it was way too damaged by the rupture, a radical but inevitable approach (salpingectomy). Fortunately, the other tube is still viable for future babies.
The experience touched me profoundly. I had been involved in chopping off part of a human being's ability to procreate... in order to save her life. Then it dawned on me: I was beginning to make decisions that would affect people's lives for ever. And there was no going back.
Yet God works in wonderful ways. Knowing how dangerous these (ruptured) ectopic pregnancies are, wasn't my friend lucky to be in the right place at the right time? I think she was divinely favored. I thank God that the surgery went well and that her life is out of danger. She is post-op day # 1 today, chilling in the ICU. Last time I talked to her she was in pain, but awfully pleased to be alive.
