Re: Ob: Chronic Ectopic? (long)
From: R. Daniel Braun (rd.braun@gmail.com)
Tue Feb 26 06:07:20 2008
Interesting! I think that you probably should address the mass. Scope or
Open Lap. You need to find out what is going on with it. Doubt that she
could have bled enough into the mass to cause her Hct to drop that far.
Path on her D&C??? Villi Yes or No????
Green J. about 1967 or 1968 article by Robert E. McCammon describes my first
experience with a chronic ectopic. It caused a recto-vaginal fistula.
Obstet Gynecol. 1967 Sep ;30 (3):414-6 6037700. Sigmoidovaginal fistula: an
unusual complication of *ectopic pregnancy*. RE *McCammon* , HE Geisler *...
Google is my friend, they weren't, they didn't even put my name on the
paper.*
I am the 2nd yr resident who sent her home saying she was 20 wks pregnant
and then readmitted her when she developed the fistula.
Any other abnormal liver Fx tests??
Persistent mole or choriocarcinoma are certainly other possibilities, even
with a relatively low hCG.
Dan
On Mon, Feb 25, 2008 at 10:10 PM, Garry E. Siegel, M.D. <
garrys@mindspring.com> wrote:
> I hope that others have some comments, and I especially look forward to
> Dan Braun's thoughts.
>
> 29 YO P2022, consult from the hospitalist service, whose history is
> obtained from the patient, husband and interpreter as she is Mexican and
> I am not fluent in Spanish, nor she is English.
>
> She was admitted today at 1 PM, as she came to the ER with a month
> history of vaginal bleeding and/or rectal bleeding. Her hematocrit was
> 18 so she was admitted to internal medicine for rectal bleeding and
> anemia, and was admitted to get a workup and blood. Oh, by the way, her
> HCG is still positive, as she had a miscarriage a month ago, treated by
> D and C.
>
> So, after getting the call for the consult around 2, I asked for a
> quantitative HCG and pelvic ultrasound, as I wouldn't see her until the
> end of the business day.
>
> Next, the radiologist tells me that his tech got a history of an ectopic
> a month ago, and she has an 8 cm. mass on the right.
>
> So, when all else failed, I went to talk to the patient and examine her.
>
> The only data that I have from elsewehre is a hematocrit on 1/31 of
> 34.6, and then one on 2/18 of 27.6. If HCGs were done (they were, I
> bet), I have no results.
>
> On questioning, she had a "cleaning out" one day, and a couple of days
> later, came in for a shot. When I said "ectopic" or "tubal" pregnancy,
> and was she supposed to get follow up visits (hey, she had blood two
> weeks later), she said yes.
>
> She has had two children at term by C/S, now ages 2 and 7, and a 2 month
> miscarriage around 2 years ago, in which she was bleeding and given a
> pill to miscarry. That resolved itself without surgery over a few days.
>
> Her exam revealed a well appearing, thin woman. She had gotten a dose
> of morphine (by the way, no complaint of pain on presentation), and her
> belly was soft, but I did have the sensation of a mass just above the
> pubis. A prior low transverse skin incision was noted.
>
> Upon pelvic examination, she had a small amount of pink dischage, and
> her cervix had a normal appearance. Her uterus was anterior and small,
> and I felt a firm, 6+ cm mass behind and to the right.
>
> The ultrasound shows a complex mass, no free fluid, and an empty uterus.
>
> Her HCG is 118, but here are some other results:
>
> Bili total around 2, SGOT 45, platelets up at 469K.
>
> My guess is some type of chronic ectopic/organized clot or process, and
> my instinct is to leave her alone, get her HCG again in a few days, and
> allow the GI doc to evaluate her history of rectal bleeding, though my
> guess is that this is secondary to some type of mass effect, if not (am
> I getting weird here) invasion of the rectum by the pregnancy.
>
> Any thoughts are welcome.
>
> Garry
>
> In questioning her
>
> --
> Garry E. Siegel, M.D.
> Private Practice
> Roswell, GA
>
--
R. Daniel Braun, MD FACOG(L) ABMP CMTh
Professor Emeritus
Dept. of Obstetrics and Gynecology
Indiana U. School of Medicine
R. Daniel Braun
"Science without Religion is LAME; Religion without Science is BLIND"
Einstein 1941
