1. Soe Lwin1, Tin Moe Nwe2, Myat San Yi1, Thidar Soe1& Mi Mi Khaing1
“A CASE OF RUPTURED ECTOPIC PREGNANCY IN BLOOD GROUP AB PATIENT AT DISTRICT HOSPITAL”
Soe Lwin1, Tin Moe Nwe2, Myat San Yi1, Thidar Soe1& Mi Mi Khaing1
1 Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University Malaysia Sarawak
2 Department of Anatomy, Faculty of Medicine and Health Sciences, University Malaysia Sarawak
Introduction
Ectopic pregnancy is a life-threatening gynaecological emergency, and significant cause of maternal morbidity and mortality worldwide. In the United Kingdom, the incidence of ectopic pregnancy is 11.5/1,000 pregnancies with 4 deaths (a rate of 0.4/1,000 ectopic pregnancies) due to higher rate of assisted conceptions techniques [2, 3]. The availability of necessary blood group plays a vital role in the management of life-threatening condition like ruptured ectopic pregnancy. A study on the distribution of the red blood cell phenotypes amongst the ethnic groups in Malaysia has shown that AB group was the rarest group comprising Malays (7.5%), Chinese (10.9%) and Indian (6.7%) among 28,334,135 populations [9]. It has been reported that only 4.6% of donor population is blood group AB Rh positive.
The management of ectopic pregnancy depends on the haemodynamic stability of the patient, level of the βhCG, and the size of the ectopic pregnancy. The standard management for ruptured ectopic pregnancy is surgical management via laparoscopy or laparotomy. In this case report, the patient with rare blood group AB was admitted to BAU hospital for ruptured ectopic pregnancy with haemorrhagic shock necessitating to undergo laparotomy. E FF
Figure1. Ultrasound finding of the patient (E: Ectopic, FF: Free fluid at Pouch of Douglas)
Case presentation
A 38-year-old parity woman of Iban origin, was admitted to the emergency department of Bau hospital presenting with acute lower abdominal pain followed by single episode of fainting attacked at home. It was associated with vomiting, diarrhoea and spotting two days ago with previous history of right tubal pregnancy managed by right partial salpingectomy in 2011.
On arrival, there were clinical signs of haemodynamic compromise, with rebound tenderness over the suprapubic area and marked cervical excitation on pelvic examination.
Ultrasound examination showed empty uterus with free fluid in pouch of Douglas and no adnexal mass as shown in figure 1. This ultrasound finding and positive urine pregnancy test supported the diagnosis of ruptured ectopic pregnancy. The blood results were haemoglobin: 5.5 g/dl with AB Rh positive blood group and platelets 110,000/ml.
She was diagnosed as ruptured ectopic pregnancy with haemorrhagic shock. On-duty medical officer of BAU stabilized the patient by giving intravenous fluid. Then the blood bank was informed for transfusion but there was shortage of blood group AB Rh positive. So the medical officer informed to the Sarawak General Hospital on call specialist regarding the situation.
The on call specialist advised to give blood group O after cross-match with patient’s blood and stabilized the patient. The mobile team which consists of anesthetist oncall, obstetrician and gynaecologist, 4 pints of AB Rh positive blood and Disseminated Intravascular Coagulation (DIVC) regimen was arranged and laparotomy was performed by mobile team at BAU hospital within one and half hour after information. At laparotomy, ruptured left ectopic pregnancy at ampullary region with dense adhesion probably due to previous operation and pelvic inflammatory disease and significant amount of haemo-peritoneum about 2 liters were confirmed as shown in figure 2 and 3. The left salpingectomy and peritoneal lavage were performed and the tissue was sent for histopathological examination. During operation she was transfused with 5 packed cells (2 O positive and 3 AB positive) and 1 cycle of DIVC regime (2 units of Fresh Frozen Plasma (FFP) & 3 units of Platelet). The postoperative period was uneventful and she was transferred to Intensive Care Unit (ICU, SGH) with ambulance under anaesthetist’s supervision. She was kept in ICU for one day and discharged from the hospital five days after operation.
The histopathology examination confirmed left tubal pregnancy. She was fully recovered after this incident. Necessary advice on contraception was counselled.
Figure2. Massive adhesion due to previous ectopic operation FF
Figure3. Left tubal pregnancy
Discussion
Since there are different presentations of ectopic pregnancy which is not easy to diagnose in the community, all reproductive women with lower abdominal pain and vaginal bleeding should be referred to the hospital as early as possible to rule out ectopic pregnancy. The diagnosis of ectopic pregnancy relies on the combination of ultrasound finding and serial serum beta-human chorionic gonadotrophin (βhCG) measurements [4,5]. The transvaginal ultrasound (TVS) provides high sensitivity in the diagnosis [1]. It can be done as early as 24 days post-ovulation or 38 days after the last menstrual period (about 1 week earlier than transabdominal ultrasonography). An empty uterus on endo-vaginal ultra-sonographic images in patients with a serum β-hCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proved otherwise [6, 7]. Although the availability of rare blood group(AB) from community is difficult in district hospital, timely provision of universal blood donor group O saved the life of the patient in this case with the possibility of adverse blood transfusion reactions like severe acute haemolytic reaction, renal failure and death.
Timely admission to the hospital, early recognition of the diagnosis, timely referral to specialist, quick response and efficient management of well-organised mobile team and prompt action taken by blood bank of SGH resulted in good outcome of this patient although there were some drawbacks like lack of expertise in district hospital and the limited facilities.
Conclusion
It is a considerable challenge to manage a patient with ruptured ectopic pregnancy at district hospital due to limited facilities of necessary blood group in emergency situation to combat shock. However, with the help of mobile team from tertiary hospital, life of the patient was saved.
Getting organized is like climbing Mt. Everest- it gets harder as you go but exhilaration once you reach the end is life changing.