Delayed Diagnosis of Ectopic Pregnancy Leads to Total Salpingectomy

This case involves a pregnant woman, previously using Yasmin, who was being followed by an obstetrician. She had her serial B-hCG level evaluated for a suspected ectopic pregnancy. No notation was made in the medical record about counseling the patient regarding the differential diagnoses of spontaneous abortion or possible ectopic pregnancy. An ultrasound that was conducted at six weeks was reported to be normal. The next assessment at seven and a half weeks noted that the patient was complaining of pelvic and rectal pain with increasing pressure. The status of this patient at this point was now changed from a normal pregnancy to ruling out ectopic pregnancy. A vaginal ultrasound performed documented a spontaneous abortion with no evidence of pregnancy and an anteverted uterus measuring 7.0 x 4.5 x 4.9cm. The next visit by the patient was to assess an evolving situation of the complex fluid building in the peritoneal space and, at this point, a definitive diagnosis of an ectopic pregnancy was made. The plan was to proceed with surgical intervention and an immediate laparoscopic abdominal surgery was performed. Following surgery, the operative note stated that a ruptured ectopic pregnancy was identified in the right fallopian tube. Subsequently, a tubal resection and total salpingectomy were performed to correct the medical emergency.

Question(s) For Expert Witness

1. At what point should an ectopic pregnancy have been included in this patient's differential diagnosis?

Expert Witness Response E-000051

Patients with early, normal intrauterine pregnancies often present with signs and symptoms similar to those encountered in patients with ectopic pregnancies and other gynecologic or gastrointestinal conditions. The availability of various biochemical, ultrasonographic, and surgical modalities can aid the healthcare provider today in establishing a definitive diagnosis and differentiating among various conditions. In order to reduce the morbidity and mortality associated with ectopic pregnancy, a high index of suspicion is necessary to make a prompt and early diagnosis. As mentioned earlier, neither risk factors nor signs and symptoms of ectopic pregnancy are sensitive or specific enough to establish a definitive diagnosis. Hence, it is necessary to screen any female patient in her reproductive years who presents with abdominal pain, cramping, or vaginal bleeding for pregnancy. Ultrasonography is probably the most important tool for diagnosing an extrauterine pregnancy, though it is more frequently used to confirm an intrauterine pregnancy. Laparoscopy remains the criterion standard for diagnosis, but its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies.