What’s the Diagnosis?
by Yash Pandya
History of Present Illness:
Lynn is a healthy 25-year-old female who is found to be alert and oriented upon contact with EMS. She presents with a chief complaint of increasing abdominal pain over the past several days, with significant worsening this morning. Her pain is located in the generalized belly region with specified pain in the left lower abdominal quadrant.
Lynn is becoming increasingly anxious and diaphoretic (sweaty) when she is brought to the Emergency Department by EMS. On examination, her abdomen is rigid and presents with some bruising around the umbilicus (belly button) and the flanks. She is starting to turn pale with loss of appropriate mental status.
Lynn has been a healthy young woman all her life. She has no known medical history and she does not take any medications on a regular basis. She does report an implanted Intrauterine Device (IUD) for contraception. Lynn is allergic to penicillin.
On arrival in the ER, Lynn is only responsive to painful stimulation. She has a Heart Rate of 120 weak and irregular, Respiratory Rate of 30 fast and shallow, Blood Pressure of 70/50, and SpO2 of 85% on high-flow oxygen. There is no gross external bleeding noted. Her blood glucose is 87 mg/dL. EKG shows atrial fibrillation.
What’s wrong with Lynn?
Lynn suffers from a classic gynecological disorder known as an ectopic pregnancy, which is characterized by the abnormal extra-uterine implantation of a fertilized ovum. Under normal conditions, an egg is fertilized by a sperm in the fallopian tube and implanted in the uterine lining for development into a fetus. In an ectopic pregnancy, the fertilized egg can implant in any location other than the uterine lining, including the fallopian tube or even the abdomen.
An ectopic pregnancy usually shows its symptoms within the first eight weeks of pregnancy, such as abdominal pain, vaginal bleeding, nausea or vomiting and dizziness. In severe cases, such as with Lynn, the development of the fertilized egg in a location such as the fallopian tube can cause eventual rupture of the structure and cause massive internal hemorrhage. The patient’s blood pressure plummets due to loss of a massive amount of blood (hypovolemia), and goes into decompensated shock, where the patient’s breathing rate and heart rate increase to maintain oxygenation and perfusion, respectively.
There are multiple different treatments for an ectopic pregnancy if caught in its early stages, such as laparoscopic interventions to remove the fertilized egg. Internal hemorrhage due to the condition can only be treated definitively by aggressive fluid resuscitation and surgical interventions.
As a rule of thumb, if you ever choose a career in medicine and come across a female patient of childbearing age with abdominal pain, it is an ectopic pregnancy until proven otherwise.