Marielle S. Gross, MD, MBE

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Aug 30 · 8 min read

A 23-year-old with an ectopic pregnancy — one implanted outside the uterus, usually in the fallopian tube — presented for a second round of methotrexate injection since her pregnancy hormone levels were still increasing two weeks after her first dose. She had never had surgery before and was afraid of going to the operating room, mainly because she was worried about coming out of it missing one of her fallopian tubes. She was right to have that concern. At that point she was asymptomatic, so it was appropriate for continued medical management. Only, when I went to place the order in the electronic medical record, I noticed someone else had just given her IV hydromorphone (Dilaudid): a potent opioid. Why was this allegedly asymptomatic patient receiving such a powerful, potentially dangerous pain medicine…?

My resident returned to her bedside in the emergency department, confirming that she was now vomiting and writhing in agony. This was highly concerning for a ruptured ectopic, a surgical emergency which usually occurs when a tubal pregnancy grows too large to be contained by the delicate but vascular tube, causing it to burst, spilling blood into the peritoneal cavity. Blood irritates the lining of the abdomen, causing extreme pain. Blood loss due to ruptured ectopic pregnancy is also a major cause of pregnancy-related mortality. At this point, emergent surgery was indicated. She and her family initially resisted the change of plans, however her pain worsened, and she ultimately agreed to operative management, pleading with the resident to save her tube if at all possible.

I take hospital call from home, so the patient was already asleep and being positioned on the operating table when I arrived. “She didn’t want surgery,” the resident said as we scrubbed. “She really wanted to keep both her tubes, so I consented her for possible salpingostomy vs. salpingectomy:” either opening the tube, removing the pregnancy tissue and stopping any bleeding, or simply removing the bleeding, abnormal-pregnancy-containing tube itself. “She is aware that we will most likely take the affected tube,” she reassured me.

…continue reading ‘”Mini-ssippi Appendectomy”

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