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Ob: Chronic Ectopic? (long)From: Garry E. Siegel, M.D. (garrys@mindspring.com)Mon Feb 25 20:08:58 2008
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
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