Best Examination Tips: Medcase, Interesting Medical Cases and Pictures

  • Sunday, July 7th, 2013

Updated 15.01.2017.

This section includes interesting medical cases to broaden and improve the awareness and knowledge. Sometimes a part of the case would be published at a time rather than the whole story to provoke thinking and discussion. Some cases, including pictures would be presented in a summarised form without exact detail. Relevant information regarding the case/medical condition/picture would be included as appropriate.

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Case 1 (07.07.2013.)

A case of acute abdominal pain with an unusual diagnosis The first case of ectopic pregnancy following tubal sterilization plus hysterectomy presented.

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This case occurred in 1998 at Arrowe Park Hospital, Wirral, UK within few months of commencing my Specialist Registrar job. The O&G Consultant involved was Mr Andrew Murray, and Mr S Majid (Staff Grade) was also involved with me at the laparoscopy/laparotomy. I met Mr Murray recently at the RCOG World Congress in Liverpool, UK in June 2013 and had mentioned that this case was accepted at the Congress. It was first presented at the North West Region Case Presentation Evening, Macclesfield, UK in 2001. Somehow I did not manage to prepare a case report to send it for publication despite thinking several times for last 15 years (not excusable, its my fault). Case report and literature review: A case of acute abdominal pain with an unusual diagnosis (ectopic pregnancy following vaginal hysterectomy) – North West Region Case Presentation Evening, Macclesfield, UK, March 2001. A Medline search performed on 19.07.2013., with the following phrases, has revealed only one more case reported in 2008. Medline search phrases included ectopic pregnancy following tubal sterilization plus hysterectomy.

Rosa M, Mohammadi A, Monteiro C. Ectopic tubal pregnancy after hysterectomy and tubal ligation. Arch Gynecol Obstet. 2009 Jan;279(1):83-5. doi: 10.1007/s00404-008-0645-0. Epub 2008 Apr 17.

Acute abdominal pain is usually associated with PID, ectopic pregnancy, miscarriage, ovarian cyst, fibroid, UTI, acute retention of urine, endometriosis, adhesions, appendicitis, gastritis, gall stone, cholecystitis, pancreatitis, IBS etc. This case was unique and therefore presented here to improve awareness.

Case report Day 1 (A&E)

A 33-years-old, P3+1 lady presented with severe lower abdominal pain of acute onset, without any exacerbating or relieving factors, since 3 hours following sexual intercourse. She also had history of nausea, dysuria and constipation for 1 week (bowel opened with fibogel). Her past medical history included laparoscopic sterilisation (5 years ago), vaginal hysterectomy (10 months ago, for DUH), 3 laparoscopies (for pain abdomen), IBS and detrusor instability. Her obstetric history included 1st – LSCS, 2nd & 3rd – SVD and 4th – Molar pregnancy. The examination findings included: pulse-102/m, apyrexial; P/A soft, no muscle guard, tenderness+++, reduced bowel sounds, no mass palpable; P/R – NAD, urine – NAD.

Impression: Obstruction secondary to adhesions following hysterectomy.

Plan: Abdominal and chest X-rays, FBC, U&Es, LFT, amylase, NBM, IVI, analgesia and refer to Surgery.

Surgical review: muscle guard+, rebound tenderness+, Hb11.3gm/dl, WCC 8.8

Impression: Diffuse peritonitis ?cause; D/W Consultant

Plan: Admit to the Surgical Ward, IV antibiotics.

Day 2 (Surgical Ward)

No improvement in patient’s condition.

Plan: Pelvic USG scan, Gynae opinion.

USG Scan findings – Complex 9×5.5 cm mass at the vaginal vault (?haematoma), moderate amount of free fluid in the pelvis.

Day 3 (Gynae Ward) TVS – echogenic ?solid mass at the vault, unsuitable for needle aspiration; Examination – extremely tender vault and lower abdomen,  right>left; Hb10.8gm/dl

Impression: Pelvic mass, unlikely to be abscess/appendicitis

Plan: Laparoscopy and ?proceed

Day 4

Laparoscopy – haemoperitoneum obscuring view, diagnosis not clear; laparotomy – haemoperitoneum+++, clots+++; ?ruptured right tubal ectopic, right fimbrial end adhered to the vaginal vault, bilateral salpingectomy performed, EBL 1 litre; blood transfusion 2 units,  serum  beta hCG,  urgent histology, methotrexate, IV antibiotics.

Day 5

Serum beta hCG 2056 IU/L (sent on Day 4) Day 6 Serum beta hCG 324 IU/L, Hb 10.5gm/dl Day 9 Histology – Right sided tubal pregnancy confirmed; patient discharged.

Discussion Ectopic pregnancy following hysterectomy

Ectopic pregnancy following hysterectomy is possible as long as the ovaries are present. Only 56 cases of ectopic pregnancies after hysterectomy have been reported. Thirty-one such cases were diagnosed and treated in the immediate period after hysterectomy (“early presentation“) and were pregnancies presumed to have been present at the time the hysterectomy was performed. Twenty-five cases of “late presentation” ectopic pregnancy after hysterectomy have been reported, certainly developing as a result of a tubo-vaginal fistula or prolapse of the fallopian tubes through the vaginal vault. The risk increases if pelvic peritoneum is not closed during hysterectomy. Sometimes the diagnosis is not even suspected until laparotomy. Every woman with intact ovaries, despite previous hysterectomy, who presents with abdominal pain, should be screened for pregnancy. “Early presentation” ectopic pregnancies can be prevented with adequate contraception before hysterectomy or by avoiding operating in the periovulatory or luteal phase of the menstrual cycle. “Late presentation” ectopic pregnancies after hysterectomy are likely to be dependent on the type of hysterectomy performed and the presence of a residual cervix.

Conclusions

Ectopic pregnancy following hysterectomy is possible as long as the ovaries are present. Only a handful of cases have been reported. This case was unique as she had both sterilisation and hysterectomy. The diagnosis was not even suspected until laparotomy.

Ectopic pregnancy Ectopic pregnancy is the implantation and development of fertilized ovum outside the normal uterine cavity. Incidence: About 1% of pregnancies Read more G-Y in Gynaecology: Ectopic Pregnancy – themedideas Facts & Figures

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Best Examination Tips: Medcase, Interesting Medical Cases and Pictures
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