Heterotopic

We see some pretty interesting stuff here.  Some of the stuff we see are things that you have only read about in books.  Medical books that is.  And sometimes you have never even read about this stuff.  

But this one I’d read about.  It’s something that’s always in the back of our minds as a possibility, but it is SOOOO RARE, that you never really give it a thought longer than a half of a second.  

It’s maybe something that that one old doctor’s colleague’s friend once saw a million years ago.  

But, no...this was not something for the books only.  This was a RARE case and it was a case for Bere Adventist Hospital.  

I had spent the last 2 or 3 hours doing consultations and helping with obstetric ultrasounds with Doudja, our radiology tech.  He also speaks a million languages (I’m sure at least 10) so I usually steal him to help translate for me too.  There were only about 3 ultrasounds left, so I went home and left the other 3 for him to finish up.  

About 10 minutes later Doudja called me.  “Doctor, I have something interesting for you.”

I finish eating my late lunch and then head back in.  Doudja calls the woman back and she walks over to the table.  She has had pain for over 3 weeks.  She has been seen at multiple health care centers and treated with various antibiotics to help her pelvic pain.  

But what Doudja found could never be treated with antibiotics.  He said he wasn’t sure of the diagnosis, but knew it wasn’t normal.  

I put the probe on her belly.  She was quite tender.  I found a 10 week sized embryo without a heartbeat.  This is termed missed abortion (baby died but hasn’t been expelled).  THAT was definitely IN the uterus.  I spanned the edges of the uterus and could see that the uterus with the 10 week miscarriage continued down to the cervix and vagina.  

But....

Then I moved the probe UP.  It was another pregnancy.  A moving, kicking little fetus.  But WHERE was it?  Was there another horn of the uterus?  Was it really outside of the uterus?  Maybe she had 2 uteri.  I scanned more and determined that it looked like an ectopic pregnancy.  If this was not operated on and removed, the mother would lose her life.  The ectopic pregnancy measured 12 weeks.  So the intrauterine pregnancy must have died 2 weeks ago and the ectopic pregnancy continued to get the blood supply from the fallopian tube.  

This is a bad picture taken of the ultrasound machine.  In the upper left you see part of the bag of the ectopic pregnancy (pregnancy outside of the uterus), and on the right you see a part of the intrauterine pregnancy (pregnancy in the uterus).  It was hard to get them both in the same picture.  

I explained to the family that we had to operate.  Today.  It would be free, so not to worry about the money.  

They said they didn’t want any more children.  She had already had 9 pregnancies, including 2 sets of twins.  Of the thirteen fetuses she had gestated over the course of her life, only four were living.

I planned on doing a laparotomy with removal of the ectopic pregnancy, tubal ligation of the other tube, and would need to do a curettage to remove the intrauterine miscarriage.  

I called Dad over to help me, and then we opened her up.  There was a lot of blood.  The 12 week baby was indeed an ectopic pregnancy and was located in the left tube.  So I removed the entire left tube.  It was adherent to the intestines a little, so we carefully separated that.  The tube didn’t actually appear ruptured, but there was still a lot of blood in her abdomen.  This must have been because the pregnancy was demanding the surrounding vessels to contribute blood to it and some of these burst.  

Because there was so much blood, I aborted my thoughts of just doing a hysterectomy for a cool picture of the ectopic and intrauterine pregnancy in the same picture.  I do have a bad picture of the ultrasound image from before the operation.  

I finished the tubal of the other side, irrigated LOTS of fluid to get rid of the blood, closed her up, and then did the curettage from below.  

She is recovering well postop now.  

It would be cool to write a case report about this.  If any budding resident is interested, I can send you the details.  They are all carefully recorded in our charting system.  Ha.