Janetha Richards was terribly excited to be pregnant, but that wasn’t the reason she fainted.

She loved kids so much that she had signed on as a teacher’s aide ather local kindergarten, and she had always wanted her own. She had beentrying to conceive for six years, but until seven weeks ago, she hadgotten nothing from her efforts except a chlamydial infection from acheating boyfriend. She had been thrilled to see the pink stripe on thehome pregnancy test kit. But she was deliberate and more than a littlesuperstitious, so she had waited to call for an obstetrician’sappointment for fear she would miscarry. After all, she’d had anepisode of spotting a month after missing her period, and she’d hadworsening cramps over the last three weeks. Then, too, she was 32,older than most of the first-time mothers in her neighborhood in southChicago.

Janetha still hadn’t called her doctor that afternoon when she felta ripping pain in her pelvis. She had struggled to keep smiling for thechildren, but she was frightened that she was losing her baby. She kepta smile on her face right up to the moment she lost consciousness.

When her ambulance pulled up to the emergency department doors atCook County Hospital, it was clear even to the medical students thatJanetha was in serious trouble. She was barely conscious, despite theintravenous fluids the paramedics had poured into her on the ride fromschool. Her smooth dark skin was ashy gray. Her pulse was racing. Thenurse couldn’t find a blood pressure reading with the automatic cuff,and when she checked with her stethoscope, it was only 70/40. Janethawas in shock.

She hadn’t told anyone she was pregnant, so it took a while for theemergency room doctors to figure out why she was dying, but only alimited number of conditions cause shock in an otherwise healthy woman.After infections are ruled out, pregnancy complications lead the list.A urine pregnancy test, drawn with the help of a bladder catheter,confirmed that diagnosis, and I was called down with the gynecologicsurgery team.

Our initial examination confirmed that Janetha was in gravecondition. I could tell from the way her belly felt that it wasdistended from blood, not from the pregnancy. Every time someonetouched her abdomen, she winced, a reaction to the blood irritating herperitoneal lining. When the emergency department staff ran blood intoher veins, she would come to, only to fade away again every time thetransfusions stopped for another bag to be hung. All the signs added upto a ruptured ectopic pregnancy.

Pregnancies are ectopic when the fertilized egg implants outside thelining of the womb, usually in the fallopian tube. The surface of thetube is normally velvety, lined by fronds that sweep the egg toward theuterus and ascending sperm. Other cells nourish the egg and providecompounds that help it mature. But endometriosis or infections likechlamydia or gonorrhea can cause some of the fronds to scar together,forming pouches that trap the egg. If fertilized, the egg grows inplace, supporting itself via placental tissues that eat into the wallof the tube and by releasing chemicals that stimulate the formation ofnew blood vessels. Unlike the uterus, the tubal wall is inelastic. Asthe embryo grows, the wall stretches until it ruptures, usually after 6to 10 weeks. Dilated blood vessels break, pouring blood into theabdomen. Without treatment, women often die.

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.