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Abstract: Ovarian pregnancy is one of the more common cases of ectopic pregnancy, which may even endanger the patient’s life if not detected in time. 25-year-old woman presented to the clinic with abdominal pain and small amount of vaginal bleeding after 40 days of menopause and was in critical condition with hemorrhagic shock. The patient was diagnosed as having an ectopic pregnancy (ovarian pregnancy) and was promptly treated clinically with surgery, during which the patient bled heavily. After proper management, the operation was successful and the patient was discharged successfully.
Basic information】Female, 25 years old
Type of disease】Ectopic pregnancy (ovarian pregnancy)
Hospital】Guangzhou Huadu District People’s Hospital
Date of Consultation】August 2020
Treatment plan】Surgical treatment (epidural anesthesia for exploratory surgery + left ovarian wedge resection) + blood transfusion
Treatment period】7 days in hospital
Effectiveness of treatment] Discharged successfully
I. Initial consultation
The patient, accompanied by her family, came to our hospital on August 9, 2020, with lower abdominal pain for 2 days, a little vaginal bleeding for 3 days, and fainting once after 40 days of menopause. The patient reported that her last menstrual period was on June 29, 2020, and she usually had regular menstruation with normal monthly volume, and she had one abortion one year ago. When she stopped menstruating for 35 days, she took an early pregnancy test with her morning urine and the result was (+), so she thought she was pregnant. However, she did not go to the hospital for examination because she was not feeling well at that time. Three days ago, she had a small amount of vaginal bleeding without any cause, mistaking it for a preterm miscarriage, so she took time off work and rested at home and took progesterone capsules orally. 2 days ago, she developed vague pain in the lower abdomen, which worsened today, and she went into hemorrhagic shock, so she came to our hospital accompanied by her family. The patient’s vital signs were measured and the results showed a basal body temperature of 36.3°C, a heart rate of 94 beats/min, a respiratory rate of 22 breaths/min, and a blood pressure of 90/50mm Hg. The patient was pale, had a painful expression and was indifferent, no abnormalities were heard on cardiopulmonary auscultation, and the abdomen was flat. The uterus was normal in size, but a significant mass was detected in the left adnexal area, about 5×5 cm in size with unclear borders, and the patient’s pain increased significantly after touching the mass. Ultrasound examination was performed, and the results showed that the uterus was not abnormal. 5×5 cm mixed mass with unclear border was seen in the left adnexal region, 0.5×0.7 cm germ tissue was visible in the mass, no primitive cardiac pulsation was seen, and a large amount of fluid 6 cm deep was seen in the pelvis. emergency blood test was performed, and the results were hemoglobin 8 g/L and blood HCG level was 4667 mIU/ml, and the preliminary diagnosis was ectopic pregnancy. and prepared for emergency surgery.
(Ultrasound)
II. Treatment history
After the family signed the consent, the patient was actively prepared for surgery, and blood and fluid transfusion was prepared to prevent intraoperative bleeding. The patient’s peritoneum was seen to be purple-blue and there was a large amount of blood after cutting the peritoneum, so the suction was turned on immediately to output the blood. The left ovary was wedge-shaped and sent for pathological examination along with the pregnancy tissue. There was no active bleeding on the local trauma, no uterine abnormality, and no abnormality on the right ovarian tube. After cleaning the abdominal cavity, there was no active bleeding on re-examination, and the inventory of instrument gauze was correct, so the abdomen was closed layer by layer and transferred to the ward, and the postoperative pathology report detected the result of left ovarian pregnancy. The patient had intraoperative bleeding of 1100mL, blood transfusion of 400mL, and supplementation with 0.9% sodium chloride injection, 5% glucose injection, compound sodium chloride injection, and indwelling catheter. Follow-up measurement of the patient’s urine was about 300mL, the urine was clear in color, and no carnal hematuria was seen. After the operation, the patient was given ferrous sulfate tablets to correct anemia and the wound dressing was changed when the patient was ventilated.
III. Treatment effect
After a series of treatment, including giving the patient blood transfusion, replenishing blood volume, strengthening abdominal wound as well as vulvar care and urinary catheter care after surgery, the patient had no cough and sputum, no lower abdominal pain, but a small amount of vaginal bleeding. On the 6th day after the operation, the patient’s hematocrit was 10g/L and blood HCG was reduced to 192mIU/ml, and the wound was healed in the first stage, with normal urine and stool and normal body temperature.
IV. Notes
We are glad that the patient was discharged from the hospital after a series of treatment and was out of danger. However, since the patient was not completely cured at the time of discharge, the following points still need to be noted in the follow-up daily life.
1. pay attention to daily supplementation of protein and vitamin-rich foods, especially pay attention to more iron-containing foods, such as pig liver, black chicken, red dates, cherries, etc.
2. After discharge, patients still need to strengthen vulva care, they can scrub their vulva with iodophor twice a day, or wash their vulva with water twice a day, during which they should pay attention to the presence of vaginal discharge, and once patients discharge tissue from the vagina, they should be sent to the hospital for examination immediately. Sexual intercourse should be avoided for 30 days after discharge, while avoiding sitz bath.
3. 3 days after discharge, the patient should return to the hospital in time for a follow-up examination and blood sampling to check the blood HCG level until the index drops to normal; 1 month after discharge, when the vaginal bleeding is clean, the patient should go to the hospital for a follow-up vaginal ultrasound to find out whether there is any abnormality in the pelvis. After discharge, attention should be paid to continue oral ferrous sulfate tablets for blood supplementation treatment, and if there is any discomfort, medical consultation should be made at any time.
V. Personal insight
Ovarian pregnancy is often aggressive and if not treated promptly, it is likely to endanger the life of the patient. In this patient, intraoperative intra-abdominal hemorrhage of 1000mL was found, and preoperative symptoms of hemorrhagic shock had already appeared, so the situation was very critical. After timely diagnosis and rescue, the patient’s life safety was successfully saved. However, after understanding this patient’s case, we should learn from it that we should not take oral medication for fetal preservation without confirming intrauterine pregnancy, so as not to make a big disaster. In addition, if there is a history of menopause but vaginal bleeding as well as lower abdominal pain is present, prompt medical attention should be sought. If the patient in this case had been detected early regarding her ovarian pregnancy, she could have taken oral medication and treated conservatively to avoid massive bleeding, which is one of the more lamentable points for us.