Re: Ob: Chronic Ectopic? (long)
From: Efrain Ramirez (eramirezt@coqui.net)
Thu Feb 28 04:09:27 2008
I know some of the listers would do a laparoscopy.. I would just go
directly to laparotomy..
Ef
>At Mon, 25 Feb 2008, Garry E. Siegel, M.D. 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
>
--
"I can accept failure, but I can't accept not trying." - Michael Jordan
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