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GYN: A plethora of repeat ectopics (long)From: Garry E. Siegel, M.D. (garrys@mindspring.com)Tue May 31 22:17:01 2005
#1 Existing patient--details from memory 32 YO P1031--term vaginal delivery 13 years ago 2001--chemical pregnancy, resolved without Rx. 2002--suspected ectopic, empty uterus, HCG over 2000, no ectopic seen. Methotrexate used successfully. 2003--ectopic seen on scan--lapscope salpingectomy--right side. 2004/2005--Clomid, doesn't conceive, headed for IVF. Conceives, HCG followed to 1800. Ultrasound shows gestational sac in left adnexum, empty uterus. Salpingectomy advised, desires ANY chance of spontaneous conception, even with high ectopic risk. Methotrexate given. HCG on administration 2500, around 5K a few days later, then falls too slowly. Repeat dose to be given, but--get this--she's out of town a few days. Upon return, HCG falling appropriately. This past weekend, 16 days after methotrexate (HCG around 2500 and falling), seen in ER with left sided pain. Exam benign, CBC normal, HCG 1500, but she has a 7 by 5 cm. mass. I suppose this is a hemorrhage into the tube due to treatment, and plan to manage expectantly with serial HCGs, CBCs, and ultasound as well as pain meds. Thoughts welcome. #2 39 YO P1011, ER patient, prev. C/S and previous ectopic 1600 hours--ER MD tells me of this patient while I'm there seeing #1. She c/o epigastric pain, has had a prior ectopic, LMP 3 weeks ago, but, hey, her Hct. is 22, WBC 34K!, creatinine 2.3. By the way, her pulse is 120 and oh, her BP is 70 systolic. Her belly is benign. Long story short, she is OTW to ultrasound and CT, and a trauma surgeon is called in, as it is *thought* via CT that her spleen is the problem and she has an abdomen full of blood. The trauma surgeon is literally taking her to the OR at 1640, as type specific blood is being rushed in. He calls me to say she might have an ectopic. I go to see her, and she isn't talking much (not much flow to the noggin). As she's going to the OR, I speak with the radiologist who confirms an empty uterus and the HCG is reported as 2200. She has at least a liter of old clot, a ripped up right tube and bleeding mesosalpinx on the right, a perforation in the left mesosalpinx (not bleeding), and a uterus stuck to the anterior abdominal wall like glue in the midline and the right, likely from the C/S. Gets 5 units and cell saver, to ICU for treatment due to shock, etc. Creatinine and BUN normal, lungs junky from pulmonary edema/shock lung?/pneumonia, but overall improving. I've not ever seen that type of presentation with such a WBC and creatinine elevation. Now that history was available, she had abdominal pain and fainted the day before. #3 36 YO P1011--very sketchy on ability to give history/poor recall/"ditzy" (sorry) ER patient Vaginal delivery 3 years ago--conceived with Clomid/IUI Summer 2004--ER patient, seen by my partner. Gets scoped for suspected ectopic with HCG around 2K, empty uterus on scan, and normal pelvis--nothing done. 10 days later, HCG 6500, re-scoped, right cornual ectopic resected. She only knows that she had an ectopic last summer on my history (I got the above after chart review), and forgot to mention the infertiity history. Anyway, she comes in with LLQ pain, HCG 2200, free fluid on U/S, and a gestational sac on the left. When seen, appears benign and stable, but I recommend surgery due to free fluid and pain. At scope, left tube has a 3 cm. unruptured corual ectopic, and a moderate amount of yellow/clear peritoneal fluid. Left tube removed, right tube is stuck to right cornua but it previously had been partially resected. I did a left salpingectomy, but retrospectively wonder if I should have bailed out and used methotrexate, although I think the tubal removal was appropriate. Opinions on all cases welcome. Garry
-- Garry E. Siegel, M.D. Private Practice Roswell, GA
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