Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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124 Surgery and Healing in the Developing World
rarely, and more dangerously, implantation occurs intra-abdominally or in the cervix.
The timing of onset of symptoms of an ectopic pregnancy roughly reflects the
location of the ectopic. If implantation is in the isthmus, rupture is typical at 4-6
weeks. Thus, one of the dangers of an ectopic is that rupture may occur before the
patient is even aware of her pregnancy. Those in the distal two-thirds of the tube
typically rupture at 6-10 weeks or develop into a tubal abortion into the abdomen at
8 to 14 weeks leading to hematocele. In the cornu and in the abdomen (e.g., on the
ovary), an ectopic pregnancy may survive to 20 weeks without symptoms.
The Unruptured Ectopic
If you are equipped with laboratory and ultrasound, it may be possible to diagnose
ectopic pregnancy early and prior to rupture. Using abdominal ultrasound, a
pregnancy is detectable at seven weeks gestational age, when hCG levels should be
5000-6000 mIU. Using transvaginal ultrasound, pregnancies are detectable at hCG
levels as low as 1500 mIU/ml. Finding a gestational sac in the uterus is helpful in
ruling out an ectopic.
If you have been able to identify an unruptured ectopic pregnancy, it may be
managed expectantly if (1) the hCG titer is falling, (2) the ectopic was less than 4
cm in size on ultrasound, and (3) it is located in the tube (i.e., a tubal abortion has
occurred). Alternatively, medical therapy with methotrexate is possible. The indications
for methotrexate are an unruptured ectopic, less than 4 cm in size, without
cardiac activity and with hCG titers below 10,000 mIU/ml. Give a single dose of
methotrexate, 50 mg/M 2 IM. Repeat hCG levels in 3 and 6 days to confirm appropriate
decline.
Rupture of an Ectopic
Acute rupture presents with sudden severe lower quadrant pain. The patient will
begin to show signs of hypovolemic shock. She is likely to be nauseated and faint.
Begin fluid resuscitation and perform a pregnancy test if materials are available. Be
aware of the sensitivity of the test kits you use to avoid being fooled by a false
negative test. Perform a gentle vaginal exam and bimanual exam—cervical motion
tenderness, tenderness or fullness in the posterior cul-de-sac palpated via the posterior
fornix, and adnexal tenderness that is greater on one side are all among the
possible findings on exam (but may be absent in over half of the cases). Consider
performing a culdocentesis and/or peritoneal aspiration to look for blood in the
cul-de-sac and in all four quadrants.
In an area where HIV is epidemic, blood transfusion may not be an option.
Commit to surgery soon and operate quickly to minimize blood loss. In developed
countries, laparoscopy is the preferred surgical approach, since it is associated with
lower risk of infection, adhesion formation and other morbidities. However, assuming
that equipment and expertise for laparoscopy will be uncommon in the mission
setting, a laparotomy approach is described below.
In the OR theatre, position the patient and establish anesthesia. Do not use
spinal block. Place a Foley and prep and drape for either a transverse or a low midline
incision. Make your incision and enter the abdominal cavity essentially as described
for Cesarean section (VI. C. below). Explore to locate the diseased tube.
Pack the intestines away. Free the diseased tube of adhesions and clot. Clamp the
fallopian tube proximal to the ectopic, incorporating mesosalpinx extending to the
midpoint of the ectopic within your clamp.