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Published byCameron Murphy Modified over 6 years ago
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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 causes major maternal morbidity and mortality with pregnancy loss in worldwide and its incidence is increasing in trend [1]. A ruptured tubal ectopic pregnancy is likely to proceed to haemorrhagic shock or even death if there is no timely diagnosis and treatment. In the United Kingdom, around 11,000 cases of ectopic pregnancy occur per year (incidence, 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 as 2-3/100 pregnancies [2, 3]. The diagnosis of ectopic pregnancy relies on the combination of ultrasound findings and serial serum beta-human chorionic gonadotrophin (βhCG) measurements [4, 5]. It is of considerable interest that in about 5%-31% of women admitted to hospital with early pregnancy problems, while pregnancy cannot be located during the first assessment, only 6-9% of them prove to be ectopic pregnancies. The transvaginal ultrasound (TVS) is providing increasing sensitivity in diagnosing a pregnancy sited outside the uterus, thus ectopic pregnancies are usually diagnosed at an early stage before rupturing [1]. Transvaginal ultrasonography, or endo-vaginal ultrasonography, can be used to visualize an intrauterine pregnancy by 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 ultrasonographic 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]. The managements of ectopic pregnancy would be depend on the patient general conditions, level of the βhCG, and the size of the ectopic pregnancy and ruptured or not ruptured. For ruptured ectopic pregnancy the standard management is surgical management by laparoscopy or laparotomy. In this patient, there had intraperitoneal bleeding and previous operation favour to do laparotomy [8]. A comparison of the distribution of the red blood cell phenotypes amongst the ethnic groups in Malaysia has been study and the blood group AB was of the lowest prevalence in Malays (7.5%), in Chinese (10.9%) and in Indian (6.7%) among 28,334,135 populations [9]. According to the report of the blood donation of the distribution of blood group, the blood group AB Rh positive group is only 4.6% of donor population and the percentage of blood issued to hospital may be increased in national blood service [10]. This is a case report of a patient who was admitted to the emergency department of Bau Hospital with signs and symptoms of haemorrhagic shock with generalized abdominal pain and AB blood group. She had fainting attacked at her home. E FF Figure1. Ultrasound finding of the patient (E: Ectopic,FF: Free fluid at Pouch of Douglas) Case presentation Figure2. Massive adhesion due to previous ectopic operation A 38-year-old parity woman of Iban origin, was admitted to the emergency department of Bau hospital with symptoms of acute lower abdominal pain and one episode of fainting attacked at home in early morning 2 am. The patient reported four times diarrhoea and two times vomiting last two days ago and spotting. She had past history of ectopic pregnancy on the right fallopian tube and open laparotomy with right partial salpingectomy been done in 2011. On her admission to Bau hospital, there were clinical signs of haemodynamic compromise, with marked tenderness on superficial and deep abdominal palpation, rebound tenderness, pallor, palpitation (121/min) and low blood pressure (70/35 mm Hg). The respiratory rate was more than 30 breath/min and SPO2 level was 92-95%. On pelvic examination, there was marked cervical excitation. The electro-cardio gram (ECG) revealed only tachycardia with sinus rhythm. Urine pregnancy test was positive and ultrasound examination showed empty uterus with free fluid in Pouch of Douglas and no adnexal mass as showed in figure 1. This ultrasound findings 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. Hence the standard treatment for this patient was to stabilize the patient condition and went operation to stop the bleeding point and removed the retained product of conception. The medical officer from Bau hospital diagnosed as ruptured ectopic pregnancy with haemorrhagic shock and she stabilized the patient condition by give intravenous fluid. Then informed to the blood bank for blood transfusion and in charge of the blood bank replied that there was shortage of blood group AB Rh positive. The medical officer informed to the Sarawak General Hospital on call specialist regarding this patient and blood problem. The on call specialist advised to give blood group O after compatibility test with patient’s blood and control the patient’s condition. After that arranged the mobile team consist of anesthetist on call, collection of AB Rh positive blood and Disseminated Intravascular Coagulation (DIVC) regime and went to the Bau Hospital. Laparotomy was performed after stabilization of the patient’s conditions, a ruptured left fallopian tube ectopic pregnancy at ampullary region with dense adhesion 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 partial salpingectomy and peritoneal lavage were performed and the tissue section was sent for histological 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 course was uneventful and she was started on Dopamine infusion and decided to transfer her to Intensive Care Unit (ICU, SGH) with ambulance. The patient’s blood sugar level was high and diagnosed as diabetes mellitus and started to give treatment with insulin injection. Patient was kept in ICU for one day and discharged from the hospital five days after the post operation. The histopathology examination confirmed a case of left tubal pregnancy. The good for prognosis of this patient were she admitted to the Bau Hospital in time, the medical officer got the correct diagnosis, gave early information to specialist, the Bau Hospital is nearest distance from the Sarawak General Hospital, the immediate arrangement of the mobile team at Sarawak General Hospital and timely operation of the patient. The drawbacks of this patient were there had no specialist in Bau Hospital and the blood group AB was not available in blood bank. But the patient had been saved her life without complications like blood transfusion reaction and operative complications. This patient was follow-up at gynaecological clinic for next one and half month and assessed the patient condition. During follow-up, her operation site was well healed and her haemoglobin level was 12 g/dl. She was counselling about her future fertility and explained about the life style. FF Figure3. Left tubal pregnancy Discussion Because ectopic pregnancy cannot be diagnosed in the community, all sexually active women with a history of lower abdominal pain and vaginal bleeding should be referred to a hospital early for ultrasonography and, if necessary, measurement of serum concentrations of βhCG. Women with a history of ectopic pregnancy should have early ultrasonography to verify a viable intra-uterine pregnancy in their subsequent pregnancies. Blood group AB Rh positive percentage is very few people in world population. Therefore the most of the blood bank have not enough blood groups AB Rh positive and negative especially in district hospital. In case of emergency, O Rh positive blood can be used in blood transfusion for AB Rh positive group after compatibility test. Much of the routine work of a blood bank involves testing blood from both donors and recipients to ensure that every individual recipient is given blood that is compatible and is as safe as possible. If a unit of incompatible blood is transfused between a donor and recipient, sever acute haemolytic reaction with haemolysis (RBC destruction), renal failure and shock is likely to occur, and death is a possibility. Conclusion An interesting finding which in our case rendered the shock condition with rare blood group and shortage of blood transfusion. Apart from that the patient had a previous operation and not suitable to do operation at district hospital. If the tertiary hospital has arrangement for mobile team, every emergency case from the district hospital would be saved their life. It is the time to consider “If you want to see Mount Everest, you first try to move Mount Everest to your place. If you can’t move it, you need to go to this place. If you want to save the patient's life and you can’t transfer the patient to your place, you need to go and save the patient yourself”.
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