Ordinarily, ectopic pregnancies are diagnosed when a pregnant woman has spotting or pain. An ultrasound scan will show an empty uterus, sometimes fluid in the pelvis from leaking blood, sometimes a mass in one tube where the pregnancy has implanted. When the ultrasound scan isn’t clear, levels of pregnancy hormones are checked for clues. Because ectopic pregnancies occur in tissue that isn’t made to feed an embryo, growth is slow, and hormone levels fail to rise normally,usually allowing diagnosis within the first eight weeks. In these cases, the pregnancy is terminated noninvasively with methotrexate, a chemotherapy drug highly toxic to growing fetal tissues; the procedure usually doesn’t preclude conceiving again. In equivocal cases, laparoscopy—a procedure in which a tiny camera and tools are inserted into the patient—can be used both to diagnose the site of the pregnancy and to treat it. A surgeon would then open the fallopian tube to aspirate the pregnancy-related tissue and seal the blood vessels with heat to control the bleeding.
Janetha’s ectopic pregnancy was neither early nor equivocal—but it was a Friday evening, and when we called the operating suite to get a room, all the teams were busy with trauma cases. To illustrate the urgency of the case, we did a culdocentesis, passing a needle through the thin layer of vaginal muscle behind the cervix where blood pools when ectopic pregnancies bleed. The syringe filled with blood. That persuaded 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 field and saw the problem. Most ectopic pregnancies implant in the thin wallof the fallopian tube between the ovary and the uterus. In Janetha’s case, the egg had almost reached the interior of the uterus but had implanted within the muscular wall of the uterus itself. The muscle there was ragged, blown open by the pressure of the growing embryo, and the uterine artery was bleeding.
The surgical solution was straightforward. We cut out the torn muscle and the bits of embryonic tissue and placenta, then sewed the right corner of the uterus back together. The stitches pinched the artery shut, and the bleeding stopped. Unfortunately, the surgical stitches also abolished the connection between the end of the fallopian tube and the uterine cavity, just as a tubal ligation would. In someone else, conception would have remained possible via the left fallopian tube. Not for Janetha. The open end of a fallopian tube is usually soft and spongy to collect eggs after ovulation, but Janetha’s left fallopian tube was scarred shut, probably because of inflammation from a chlamydial infection.
Janetha would never be able to conceive without in vitro fertilization 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 the Southern Illinois University School of Medicine in Springfield. The cases in Vital Signs are true, but names and other details have been changed.