Case Protocol
Presented by:
Clerk Jane Abigail A. Fajardo
Consultant Mentor: Dr. Manabat
Resident Mentor: Dra. Cerna
General Data:
• I.A.
• 36 year old
• G4P2(2012)
• Married
• Filipino
• Catholic
• Las Piñas City
• 2nd admission April 2,2009
Chief Complaint:
Hypogastric pain
Past Medical History:
• No hypertension
• No diabetes
• No heart disease
• No asthma
• No known allergy to food and drug
• S/P Ex Lap Salpingectomy Left for unruptured
Ectopic Pregnancy - 2001
Family History:
• No hypertension
• No diabetes
• No heart disease
• No asthma
Personal and Social History:
• high school graduate
• housewife
• non-smoker
• non-alcoholic beverage drinker
Personal and Social History:
• Married for 11 years to a 35 year old driver, assigned
to different locations
• first coitus at 24 years old, monogamous
• 1 sexual partner who claims to be non-promiscuous
Menstrual History:
Menarche: 11 years old
Interval: regular
Duration: 3-5 days
Amount: 3 pads/day moderately soaked
Symptoms: Dysmenorrhea on 2nd day of menses
Gynecologic History:
• No history of any oral contraceptive pills or any
forms of contraception use
• No pap smear was done
• No dyspareunia
• No leucorrhea
• No post coital bleeding
• No history of sexually transmitted disease
Obstetric History:
G4P2 (2012)
No. of Date Outcome Weight Anom/Com Place
Pregnancy plication
G1 1997 NSD Full Term 7 lbs None House
Girl
G2 2001 Ectopic UPHDMC
Pregnancy,
Left
unruptured
S/P Total
Salpingecto
my Left
G3 2004 NSD Full Term 6.5 lbs None House
Girl
G4 Present
pregnancy
LMP : Jan. 29, 2009
AOG : 9 weeks 1 day
EDC : Nov. 4, 2009
History of Present Pregnancy:
• amenorrheic for 9 weeks and 1 day
• No pregnancy test was done
• No prenatal check up was done
• 1 week prior to admission, on and off hypogastric
pain, colicky in character, tolerable in intensity,
non-radiating
• No dysuria, no bleeding, no vomiting
History of Present Pregnancy:
• No medication taken, no consult was done
• few hours prior to admission, experienced severe
hypogastric pain
• heavy in character with a pain scale of 6/10 radiating
to lower back
• persistence of hypogastric pain
• consult at the emergency room and was subsequently
admitted
Physical Examination:
General Survey : Patient is conscious, coherent,
walks with assistance, pale looking and not in
respiratory distress.
Vital Signs:
BP: 90/70mmHg
PR: 115bpm RR: 19cpm T: 36.3˚C
Ht: 5’4”
Wt: 124lbs
Physical Examination:
SHEENT: good skin turgor, warm to touch, pale
palpebral conjunctivae, anicteric sclera, no cervical
lymphadenopathies
Breast: slightly engorged, brownish nipple, no mass
and tenderness
Physical Examination:
Chest and Lungs: Symmetrical chest expansion, no
retractions, clear breath sounds
Heart: Adynamic precordium, tachycardic, regular
rhythm, no murmur
Physical Examination:
Abdomen: flat, soft, with direct tenderness on the
hypogastric area, and has direct and rebound
tenderness on the right lower quadrant, negative in
kidney punch, with normoactive bowel sounds
Physical Examination:
Pelvic Exam:
Gross exam of external genitalia: fair distribution
of hair, no lesions, no mass
Speculum exam: cervix pink, smooth, with scanty
bleeding
Internal exam: cervix closed, soft, uterus slightly
enlarged, there was cervical motion tenderness, with
right adnexal tenderness, no mass appreciated, no
left adnexal mass or tenderness
Physical Examination:
Extremities: full equal pulses, no cyanosis, no
edema
Working Impression:
Ectopic Pregnancy, right 9 1/7 wks AOG
G4P2(2012)
S/P Ex-lap Salpingectomy, Left for Ectopic
Pregnancy
Basis:
Amenorrhea (9 1/7 weeks)
History of prior ectopic pregnancy
Hypogastric pain, sudden in onset
Direct and rebound tenderness at right lower
quadrant
Scanty bleeding per os
Differential Diagnosis:
RULE IN RULE OUT
1. Threatened Abortion Vaginal bleeding
Lower abdominal cramping
2. Acute Appendicitis Right lower quadrant pain Amenorrhea
Vaginal bleeding
Direct and rebound
3. Pelvic Inflammatory
tenderness at the right Vaginal discharge
disease
lower quadrant
Cervical motion
Amenorrhea
tenderness
Right adnexal tenderness
Vaginal bleeding
Initial Plan:
Request for some diagnostic tests:
• Pregnancy test
• Transvaginal ultrasound
• CBC
• Urinalysis
However,
• blood pressure was palpatory 60
• tachycardic (130bpm)
• no loss of consciousness
• Increasing intensity of hypogastric pain
Admitting Diagnosis:
Hypovolemic shock secondary to
Ruptured Ectopic pregnancy, right
G4P2(2012)
S/P Ex-lap Salpingectomy, Left for Ectopic
Pregnancy
Plan:
• Exploratory Laparatomy, Salpingectomy, right for
ruptured ectopic pregnancy
• Blood Transfusion
Intra-operative Findings:
• Hemoperitoneum approximately 500cc
• Right fallopian tube is dilated to 3x2 cm at the
ampullary area with 0.5 cm point of rupture.
• Bleeding coming from the fimbriated end.
• On cut section, revealed fleshy brown material.
• Absent left fallopian tube
• Bilateral ovaries grossly normal.
Tubal Pregnancy
Final Diagnosis:
Tubal Pregnancy, Right ruptured S/P Exploratory
Laparotomy Left for Ectopic Pregnancy
G4P2 (2022)
Discussion:
Ectopic pregnancy is a
• complication of pregnancy in which the ovum is
implanted in any tissue other than the uterine
wall.
• Most ectopic pregnancies occur in the fallopian
tube but implantation can also occur in the cervix,
ovaries, and abdomen.
• can lead to massive hemorrhage, infertility, or
death.
Etiology:
The following risk factors have been linked with ectopic
pregnancy:
Pelvic inflammatory disease
History of prior ectopic pregnancy
History of tubal surgery and conception after tubal
ligation
Use of fertility drugs or assisted reproductive
technology
Use of an intrauterine device
Increasing age
Smoking
Pathophysiology:
• Fallopian tube – 98% most common
• Ampullary – 80%
• Isthmic segment of the tube – 12%
• Fimbria – 5%
• Cornual and interstitial region of the tube – 2%
Pathophysiology:
Symptoms:
The early signs are:
Pain in the lower abdomen, and inflammation
Pain while urinating
Pain and discomfort, usually mild
Vaginal bleeding, usually mild
Pain while having a bowel movement
Symptoms:
More severe internal bleeding may cause:
• Lower back, abdominal, or pelvic pain
• Shoulder pain
• cramping
• recent onset of pain
Diagnosis:
• Pregnancy test
• Transvaginal ultrasound or pregnancy ultrasound
• Quantitative HCG Blood test
• Laparoscopy or laparotomy
• Culdocentesis
Treatment:
Nonsurgical treatment
• Methotrexate - can disrupt the growth of the
developing embryo causing the cessation of
pregnancy.
Treatment:
Surgical treatment
• Laparoscopy or Laparotomy
• Salpingostomy
• Salpingectomy
Thank you
and
Good Day !!!
