''Chronic' ectopic pregnancy [s8](ectopic pregnancy without massive abdominal bleeding)

Two kinds of ectopic pregnancy do not cause massive bleeding: (1) An acute ectopic which has, so far, only caused a small bleed, and a massive bleed is to follow later. (2) A ''chronic ectopic' in which repeated small bleeds have caused a haematoma (pelvic haematocele) containing 100 to 500 ml of blood and clot. Some of these chronic cases resolve without treatment, but don't wait for this to happen. You can never be sure that the patient will not have another larger bleed, and they can cause much trouble.

A patient with a chronic ectopic may present with varying combinations of the following: (1) Lower abdominal pain, perhaps combined with pain on micturition, defaecation, or sex. (2) A small dark vaginal blood-loss (less than a normal period), perhaps preceded by amenorrhoea, and sometimes with the passage of a decidual cast. (3) A mass in her lower abdomen, at the side of her uterus, or in her pouch of Douglas. Occasionally, if her adnexae have a long pedicle, this mass is entirely outside her pelvis. Moving her cervix is painful, but this is not such a reliable sign as in an acute rupture. Her uterus is usually slightly enlarged.

The diagnosis of a chronic ectopic can be difficult, and is often missed. Its symptoms are like those of PID; if she has had several similar attacks without any missed periods, she probably does have PID.

THERESA (24 years) was seen in hospital complaining of heavy prolonged bleeding for 5 days. She had missed two periods and said that she had passed clots. She was anaemic, her uterus was slightly enlarged, and her cervix was closed and still bleeding. A doctor diagnosed her as having an incomplete abortion, and did a ''D and C'. There were few curettings, so he thought ''she must have had a complete abortion''. He gave her iron tablets and discharged her, but she continued to bleed and have low abdominal pain. So she went to another hospital where the doctor there felt a tender mass on the left side of her uterus. He thought at first that she had an ectopic, but he read the discharge card from the first hospital, which said that she had had an incomplete abortion, and a ''D and C'. So he ]]was misled and diagnosed PID with a tubo-ovarian abscess. He gave her antibiotics, and she went home. Nearly a month later she went to a private clinic run by a medical assistant. He correctly diagnosed an ectopic pregnancy, before even doing a vaginal examination, and referred her. Her haemoglobin was 40 g/l. She had had 5 children, so at laparotomy her tubes were tied. LESSONS (1) Don't be misled by other people's clinical opinions. (2) ''Abortions' may be ectopics. (2) PID can produce symptoms which are very like those of a chronic ectopic pregnancy. (3) This patient has some of the features of a subacute ectopic (severe anaemia), and some of those of a typical chronic ectopic pregnancy (a history of chronic pain); this shows that there is no sharp borderline between these two conditions. (4) Before you diagnose PID, stop and think[md]''Could this be a chronic ectopic?''. DON'T FORGET THE POSSIBILITY OF AN ECTOPIC PREGNANCY IN A WOMAN OF CHILDBEARING AGE Fig. 16-6a A LARGE PELVIC HAEMATOCELE (chronic ectopic pregnancy). You will only make the diagnosis if you think of this whenever you see a patient with irregular, missed, or prolonged periods. From Young, James, ''A Textbook of Gynaecology; (5th edn. 1939), Fig. 101. A and C Black.

CHRONIC ECTOPIC PREGNANCY DIAGNOSIS. You will only make the diagnosis if you think of a chronic ectopic pregnancy whenever you see a patient with irregular, missed, or prolonged periods. Ask her if she has low abdominal pain, and examine her for tenderness. Examine her vaginally and look for slight vaginal bleeding. Move her cervix and feel for tenderness on either side. If you can feel a mass, or tenderness which is greater on one side than on the other, she may have an ectopic.

The diagnosis may be difficult to confirm. She has no evidence of blood loss (except perhaps one or more episodes of fainting). She may be anaemic. A pregnancy test may or may not be positive.

CULDOCENTESIS is the confirmatory test for rupture of a chronic ectopic pregnancy, or a pelvic abscess. It is only positive if the haematocele is in her pouch of Douglas, and not if it is elsewhere (unusual). You can do a culdocentesis in the ward without an anaesthetic. But do it in the theatre after induction if: (1) she has a pelvic mass which could be a chronic ectopic pregnancy for which she will need a laparotomy. Or, (2) she has a pelvic abscess which needs drainage.

Put her into the lithotomy position, Clean her vulva and do a careful bimanual examination, feeling for a mass. Insert a sterile bivalve speculum. Clean her vagina with 1% chlorhexidine. Stab a 1.2 mm needle on a 20 ml syringe through her posterior fornix 1 cm behind her cervix. Withdraw the plunger.

If you withdraw more than 2 ml of dark or free-flowing fresh blood, often with bits of clot in it, she has blood in her peritoneal cavity, probably from an ectopic pregnancy.

If you aspirate a little fresh blood which clots easily, you have punctured a blood vessel.

If you aspirate nothing, or only a little fresh blood which clots easily, there is either no ectopic pregnancy, or her pouch of Douglas is obliterated by adhesions.

If you aspirate pus, she has pelvic peritonitis or a pelvic abscess.

CAUTION ! A negative test makes an ectopic pregnancy unlikely, but does not exclude it. (2) The test is only positive if you aspirate blood which does not clot when you leave it in a tube for 10 minutes. If it clots after removal, it is probably venous.

DIFFERENTIAL DIAGNOSIS. The main one is PID, see also Section 6.6. The important features are the volume, appearance, and timing of the blood loss, the history of missed periods (in an ectopic) and of fever (in PID). Culdocentesis should distinguish them.

Suggesting a chronic ectopic[md]one or more missed periods. Anaemia, which may be severe. No fever. Little vaginal bleeding not defined into periods. No obvious relationship between low abdominal pain and ''periods'. Sometimes a history of faintness when the pain started.

Suggesting PID[md]no missed periods. No obvious anaemia. Fever, which may be severe. Low abdominal pain which is often worse during and after periods, and which usually begins after the bleeding starts. A vaginal discharge, which may only be mild. No history of faintness.

Other pitfalls: (1) If she believes she is pregnant, and bleeds vaginally, you may think that she has a threatened abortion, especially if the haematocele surrounds a normal-sized uterus, and makes it appear to be enlarged to that of a 10- or 12-week pregnancy. (2) If she has passed a decidual cast, you may think she has a complete or incomplete abortion. (3) If you feel what you think is an enlarged uterus (a uterus surrounded by haematocele) in the presence of abnormal bleeding, you may think she has fibroids. (4) If the mass is difficult to feel you may think she has DUB (dysfunctional uterine bleeding, 20.2).

LAPAROTOMY. Proceed as in Section 16.6 where relevant.

You will find blood in her pelvis, mostly in her pouch of Douglas and mostly clotted. Clean it out. Find the tube which has the ectopic and do a salpingectomy, as in Fig. 16-5 and Section 16.6.

DIFFICULTIES [s7]WITH A CHRONIC ECTOPIC PREGNANCY See also Section 16.6.

If there are MANY DENSE ADHESIONS between the ectopic pregnancy and her surrounding organs, scoop out as much blood clot as will easily come out without tearing and pulling. If you try to remove firmly adherent clot, there will be much oozing. Don't try to remove the whole ''wall' of the haematoma cavity, or you may injure her gut.

If the surfaces of her pelvic organs are congested and OOZE BLOOD, as may happen when blood has been present in her pelvic cavity for some days, control bleeding with warm abdominal packs.

If you INJURE HER RECTUM or sigmoid colon (this should be rare), suture the injury, and do a transverse colostomy (9.5). Pass a drain down to the site of the repair, and close her abdomen. Close the colostomy at a convenient time later.

If you INJURE HER SMALL GUT (this should also be rare), and the injured area is healthy, anastomose it. If the injured area is inflamed, resect a length of gut and do an end to end, or side to side, anastomosis. If this is not possible, exteriorize (9.5) a loop of gut proximal to the lesion, and make an ileostomy. Later, refer her for expert repair.