Pictorial case study: Ectopic pregnancy

The case
A 36-year-old woman attended with pain in the lower left quadrant of her abdomen that had been present for about eight hours. She had no gastrointestinal symptoms, but her last menstrual period was six weeks ago, and a urinary pregnancy test she did two days ago was positive.

She was surprised because she was sterilised with a tubal ligation three years ago. What is the diagnosis, management and differential diagnoses?

Diagnosis and management
The diagnosis is suspected ectopic pregnancy. Refer to hospital as an emergency for laparoscopy, and if necessary, left salpingectomy. About one third of pregnancies following tubal ligation are ectopic.

Ectopic pregnancy should be suspected in any woman of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or haemorrhagic shock.

Possible different diagnoses

  • Perihepatitis.
  • Acute salpingitis.
  • Irritable bowel syndrome.

Differential diagnosis
Perihepatitis

  • Manifests itself as so-called ‘violin-string’ adhesions between the liver and the parietal peritoneum.
  • The association of perihepatitis with acute salpingitis (in this case caused by the ectopic pregnancy) is called the Fitz-Hugh and Curtis syndrome, described by them in 1930.
  • In the acute phase of the Fitz-Hugh and Curtis syndrome, the patient may complain of right upper quadrant pain.
  • Once the acute phase has past, right upper quadrant pain is rarely reported.
  • Treatment is with appropriate antibiotics for acute salpingitis and perihepatitis.  

Contributed by Dr Keith Barnard, a former GP in Fareham, Hampshire

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