Misdiagnosis

Okay, so this one will be a little humbling for me.  If you are an OB/GYN or an ultrasound tech, yes, you can make fun of me.  However, you are not here, and I have no idea how I missed this.  I’ve done many, many d&c’s and many, many ultrasounds before.  Thankfully God was gracious.  

She first presented last week.  G2P1000 at “9 months pregnant” and heavy vaginal bleeding a couple days ago.  The bleeding had subsided and was very minimal now.  She came into my office alone.  She had no family with her.  She showed me her carnet (medical booklet).  She actually had labwork done already from Kelo (a rarity).  Positive pregnancy test.  A little anemic with a hemoglobin of 8.  Someone else had done an ultrasound too and found a molar pregnancy.  She came to us because she didn’t have any money or maybe they referred her to us, I couldn’t really tell.  

Okay, this shouldn’t be too hard.  We have lots of these.  I’ll just confirm with an ultrasound.  A molar pregnancy is an abnormal pregnancy that doesn’t develop into a baby.  It’s a gelatinous tumor that grows inside of the uterus.  To fix it, you do a d&c (scrape out the uterus) and make sure she doesn’t get pregnant for a year or else it can come back again.  

I put the ultrasound probe on her belly.  Sure enough, it looked exactly like a molar pregnancy.  We see them at very advanced gestational ages here (9 months), so they can look truly pregnant.  

I noticed that her first pregnancy was a c-section, but the baby had died at delivery.  So she had no living children.  

The next day I started the d&c.  I had a really hard time getting her cervix dilated.  It didn’t help that my dilators are not increasing in size very well.  One of them is broken in two also, so you can easily puncture your glove if you are not careful putting it in with your thumb.  I couldn’t get her dilated very far, but managed to get a small curette in.  I was showing Samedi how to use the manual suction curette set, so also used this to help get some of the liquid out.  I found a few pieces of placenta and fluid, but did not get the satisfying grape-like gelatinous material that is common to classic molar pregnancies to come out.  I guessed that it was old and possibly attached to the uterine wall.  

Try as I might I could NOT get all of the material out of the uterus.  I was nervous I had perforated her uterus because it just didn’t feel right.  I decided to quit because her cervix was tearing and I couldn‘t get all of the tumor to come out.  I was worried about a perforation also, but decided not to open her abdomen.  

The next day she was doing  okay.  She had a little more pain than I wanted after a d&c, so I kept her.  The following day I repeated the ultrasound.  The tumor seemed to have grown.  It was bigger and the fluid seemed to have come back.  There was still a lot of tissue that needed to come out.  

I discussed her options.  I could try again with a d&c again, but she would probably need a hysterectomy because the tumor was so attached to her uterus, and I doubted I could get it out.  This was sad because she had no children.

She went home for the weekend and came back early on Sunday with a little more pain.  

Today on Monday we operated.  I had my dad help me to see what he thought. The spinal didn‘t work very well, so we had to change her to ketamine.  It took us forever to get her dilated as her cervix was already fragile from the other surgery too.  Finally we were able to get a curette inside her uterus.  I used the ultrasound probe to look also at our position.  That is definitely not in the uterus (where it is supposed to be).

It looked like we perforated this time anteriorly.  Dad agreed that something just didn’t feel right.  Dad asked, “what is this mass that feels separate higher up?” 

We decided to open her abdomen .  This was the best decision all week.  We cut out her old midline scar.  Cut down to the fascia and entered the peritoneum.  I wasn’t expecting what I saw.  

Just below the fascia was dark, blood stained omentum.  It looked angry, possibly like cancer.  Oh, that’s sad.  How could I have missed cancer?  

I stuck my hand through the fragile peritoneum to enter the abdomen.  As I stuck my hand in, out popped something that I could not believe my eyes.  It was a baby hand.  Don’t get happy, it wasn’t alive, but it was so unbelievable.  How did I miss THAT on the ultrasound?  I have no idea.

What we found in her abdomen was an abdominal ectopic pregnancy of about 7 months.  The baby had been dead a while, but weighed 1.3 kg already (about 3 pounds).  The uterus was actually a normal SMALL size.  The placenta was slightly attached to the right tube, over the uterine fundus (top of the uterus), and attached to the colon and small intestines.  It was so old and degenerated that it didn’t bleed much.  

We took out the baby, placenta, and right tube, and oversewed the colon.  There was a small perforation anteriorly in the uterus and through the fundus.  I oversewed these small places and irrigated a lot.  

The good news is that she should do fine.  And she should be able to have another pregnancy and a chance to have a live baby.  God also protected her intestines from my sharp curette and my suction curette (it’s normally supposed to stay in the uterus and not go outside of the uterus where the intestines are).  The placenta was in the way of the intestines the whole time, which explains why I was able to get placenta fragments during the d&c.  There was no perforated bowel.  

The bad news is that I’m an idiot sometimes.  This time in particular with her late diagnosis of a 7 month old ectopic abdominal pregnancy.  This is something truly very rare and only exists in 3^rd world countries I believe.  The other good news is that nobody sues here and therefore I can share my stories with you.  They are just happy to have help.  

This patient later shared with me that she had felt her baby moving earlier in the pregnancy.  She got into a fight with another woman who hit her abdomen.  She didn’t feel her baby move after that.  That had been 3 months earlier.  So her baby had probably been dead for 3 months.  

You just never know what’s going to come in here.