A 36-year-old female presented to the emergency department (ED) with a 3-day history of diarrhoea (approximately 5 episodes per day). The diarrhoea initially had a small amount of blood but had subsequently become green and very offensive. She had been diagnosed with gastroenteritis by her GP, however the patient could identify no causative factor. The day before this attendance she had developed sharp and intermittent upper abdominal pain. The pain had no exacerbating factors and she had been apyrexial and systemically well throughout the entire episode.
Whilst taking a thorough history it was disclosed that she was currently 10 weeks gestation and had undergone 2 ultrasound scans in early pregnancy at another hospital due to previous PV bleeding episodes. These scans were described as “normal” by the patient but she had no record of the results with her on this visit.
With ectopic pregnancy as one of the key differentials that would need to be excluded, the early pregnancy assessment unit where the scans were performed were contacted, who were thankfully able to confirm a single intrauterine pregnancy with no evidence of any ectopic pregnancy.
The incidence of implantation of the gestational sac outside the uterus has increased and occurs in 1% of pregnancies in the UK (Wyatt et al 2012). Throughout early pregnancy, the potential for ectopic pregnancy needs to be ruled out before considering other aetiologies of the acute abdomen (Pallavee et al 2015). Patients with ectopic pregnancy commonly present with abdominal pain, with or without vaginal bleeding, most frequently between 6 and 10 weeks gestation (Murray et al 2005). It represents a significant risk to life and is the leading cause of pregnancy related death in the first trimester (Sivalingam et al 2011).
There are a number of classical symptoms that may alert the clinician to the potential of the condition (Wyatt et al 2012):
- Sudden severe lower abdominal pain
- Collapse or fainting
- Vaginal bleeding
- Shoulder tip pain
- Features of hypovolaemia
- Nausea and vomiting (also common)
Unfortunately, presentations of an atypical nature are also relatively common and it is necessary for all clinicians to also be aware of these potential mimics, a number of which are demonstrated below (Sivalingam et al 2011):
- Spontaneous abortion
- Ovarian torsion
- Urinary tract infection
- Gastrointestinal diseases
A report by Lewis (2011) in conjunction with the Centre for Maternal and Child Enquiries (CMACE) found that two-thirds of patients who died from early ectopic pregnancy presented with only diarrhoea, vomiting or dizziness. This report also highlighted that most of the deaths were misdiagnosed in either a primary care or ED setting (Lewis 2011) meaning that clinicians need to remain suspicious of this diagnosis and extremely vigilant when any woman of a reproductive age presents with the aforementioned symptoms (Sivalingam et al 2011).
It is important to confirm pregnancy with a urinary β human chorionic gonadotropin (β-HCG) however this will not confirm the location of the gestational sac (Murray et al 2005). It is possible to perform serum β-HCG measurements although in ectopic pregnancy they may present with either falling, rising or plateau levels meaning a single measurement in the ED does not add diagnostic benefit (Murray et al 2005).The diagnosis of ectopic pregnancy is therefore only definitively diagnosed by visualisation of the embryo and gestational sac on ultrasound (Sivalingam et al 2011) necessitating referral to inpatient gynecological teams for further management and investigation.
In this case it was possible to exclude an ectopic pregnancy as she had an ultrasound, which had excluded this previously. The symptoms that she had presented with were quite non-specific and did not fit with what would be considered to be “classical” of this diagnosis.
It is clear however, that not all presentations of ectopic pregnancy are classical and there have been a number of reports where misdiagnosis in the ED, based upon non-specific symptoms, has led to patient deaths. This therefore requires clinicians to have a high index of suspicion when assessing and treating females in early pregnancy.
Driscoll, J. (2007) Practicing clinical supervision: a reflective approach for healthcare professionals (2nd edition). Elsevier. Edinburgh.
Lewis, G. (2011) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer- 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Wiley Blackwell. London. Available from: http://www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008.pdf (Last accessed 5/9/15).
Murray, H., Baakdah, H., Bardell, T & Tulandi, T. (2005) Diagnosis and treatment of ectopic pregnancy. Canadian Medical Association Journal. Volume 173, number 8, pp905-912.
Pallavee, P., Samal, S., Gupta, S., Begum, J & Ghose, S. (2015) Misdiagnosis of abdominal pain in pregnancy: acute pancreatitis. Journal of Clinical and Diagnostic research. Volume 9, number 1,pp5-6.
Sivalingam, V. A., Duncan, W. C., Kirk, E., Shephard, L. A & Horne, A. W. (2011) Diagnosis and management of ectopic pregnancies. Journal of Family Planning and Reproductive Health Care. Volume 37, number 4, pp231-240.
Wyatt, J., Illingworth, R., Graham, C & Hogg, K. (2012) Oxford handbook of emergency medicine (4th edition). Oxford University press. Oxford.