Ordinarily, ectopic pregnancies are diagnosed when a pregnant womanhas spotting or pain. An ultrasound scan will show an empty uterus,sometimes fluid in the pelvis from leaking blood, sometimes a mass inone tube where the pregnancy has implanted. When the ultrasound scanisn’t clear, levels of pregnancy hormones are checked for clues.Because ectopic pregnancies occur in tissue that isn’t made to feed anembryo, growth is slow, and hormone levels fail to rise normally,usually allowing diagnosis within the first eight weeks. In thesecases, the pregnancy is terminated noninvasively with methotrexate, achemotherapy drug highly toxic to growing fetal tissues; the procedureusually doesn’t preclude conceiving again. In equivocal cases,laparoscopy—a procedure in which a tiny camera and tools are insertedinto the patient—can be used both to diagnose the site of the pregnancyand to treat it. A surgeon would then open the fallopian tube toaspirate the pregnancy-related tissue and seal the blood vessels withheat to control the bleeding.
Janetha’s ectopic pregnancy was neither early nor equivocal—but itwas a Friday evening, and when we called the operating suite to get aroom, all the teams were busy with trauma cases. To illustrate theurgency of the case, we did a culdocentesis, passing a needle throughthe thin layer of vaginal muscle behind the cervix where blood poolswhen ectopic pregnancies bleed. The syringe filled with blood. Thatpersuaded the surgical nurses to free an operating room for us.
When we opened Janetha’s abdomen, at first we saw nothing but clots.We took out three quarts of blood, more than half her blood volume.With that cleared away, we pulled her uterus into the surgical fieldand saw the problem. Most ectopic pregnancies implant in the thin wallof the fallopian tube between the ovary and the uterus. In Janetha’scase, the egg had almost reached the interior of the uterus but hadimplanted within the muscular wall of the uterus itself. The musclethere was ragged, blown open by the pressure of the growing embryo, andthe uterine artery was bleeding.
The surgical solution was straightforward. We cut out the tornmuscle and the bits of embryonic tissue and placenta, then sewed theright corner of the uterus back together. The stitches pinched theartery shut, and the bleeding stopped. Unfortunately, the surgicalstitches also abolished the connection between the end of the fallopiantube and the uterine cavity, just as a tubal ligation would. In someoneelse, conception would have remained possible via the left fallopiantube. Not for Janetha. The open end of a fallopian tube is usually softand spongy to collect eggs after ovulation, but Janetha’s leftfallopian tube was scarred shut, probably because of inflammation froma chlamydial infection.
Janetha would never be able to conceive without in vitrofertilization techniques, which public insurance rarely covers. Butwithin two months she was back at kindergarten, caring for her kids.
Stewart Massad is chief of the gynecologic oncology division at theSouthern Illinois University School of Medicine in Springfield. Thecases in Vital Signs are true, but names and other details have beenchanged.