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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 158-163

Ectopic pregnancy: “THE MASQUERADER” -A challenge to medical fraternity


Department of obstetrics and Gynaecology, Dr. Pinnamaneni Institute of Medical Sciences and Research Foundation, Chinoutpally, Vijayawada, Andhra Pradesh, India

Date of Submission18-Apr-2021
Date of Decision07-Jun-2021
Date of Acceptance09-Jun-2021
Date of Web Publication17-Mar-2022

Correspondence Address:
Dr. Kavitha Garikapati
Department of Obstetrics and Gynaecology, Dr. Pinnamaneni Institute of Medical Sciences, Chinoutpally, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_45_21

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  Abstract 


Background: Ectopic pregnancy is a medical emergency with incidence of about 1-2% of all reported pregnancies and is termed as a ''Masquerader'' due to variable presentation.
Aims and Objectives: To study ectopic pregnancy cases with atypical presentation, diagnosis initially missed by attending physician. Objectives are to study the prevalence of ectopic pregnancies, variable presentations and outcome.
Methods: It is a retrospective observational study done in the department of obstetrics and gynaecology of a rural tertiary centre for a period of four years (January 2016- January 2020). Study population is 36. Results are analysed by descriptive analysis.
Results: Out of 5400 deliveries, 100 were ectopic pregnancies (2%) of which 36 cases presented with atypical presentation (36%). Two (5.5%) with heavy menstrual bleeding with severe anaemia, two (5.5%) with pain abdomen and distension, six (16.7%) with myalgia, six (16.7%) pain abdomen with normal cycles, six (16.7%) pain abdomen with spotting per vagina (p/v) on and off, four (11.1%) Intrauterine contraceptive device (IUCD) insitu, five (13.9%) chronic pelvic inflammatory disease (PID), four (11.1%) fainting attack with no missed period, one (2.8%) bad obstetric history, recurrent tubal ectopic with pregnancy of unknown location (PUL).

Keywords: Atypical presentation, ectopic pregnancy, masquerader, pain abdomen


How to cite this article:
Garikapati K, Gogineni S, Prasuna NJ, Eda V. Ectopic pregnancy: “THE MASQUERADER” -A challenge to medical fraternity. J NTR Univ Health Sci 2021;10:158-63

How to cite this URL:
Garikapati K, Gogineni S, Prasuna NJ, Eda V. Ectopic pregnancy: “THE MASQUERADER” -A challenge to medical fraternity. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Nov 30];10:158-63. Available from: https://www.jdrntruhs.org/text.asp?2021/10/3/158/339806




  Introduction Top


When fertilized ovum gets implanted at sites other than normal position in uterine cavity, it is known as ectopic pregnancy. It is a disaster of human production and is the most important cause of morbidity and mortality in the first trimester.[1]

Ectopic pregnancy is often termed as “MASQUERADER” because of its variable presentation. Hence diagnosis is frequently missed by the attending physician. About 95 to 98% of all ectopic pregnancies are tubal in origin.[2]

Incidence of ectopic pregnancies is 1 to 2% of all reported pregnancies. The classical triad of symptoms is pain abdomen, amenorrhea and aberrant menses, though all the symptoms may not be present at a given time.

Women may present with nonspecific symptoms, unaware of ongoing pregnancy or may present with hemodynamic shock.

Risk factors like tubal sterilization, artificial reproductive techniques (ART), IUCD, multiple sexual partners, PID, infertility, tubal corrective surgery, prior abdomen or pelvic surgeries have been implicated in the development of ectopic pregnancy.[3]

A knowledge of associated risk factors helps to identify women at higher risk in order to facilitate early and more accurate diagnosis because of the variety of symptoms that may occur, ectopic pregnancy has been called the “great masquerader.” The classical clinical triad is seen in less than 50% of cases.[4]

The study by Gaskins et al.[5] reminds us that while sexually transmitted diseases (STI) contribute to a major cause of ectopic pregnancies, there is a strong epidemiological and experimental evidence that ectopic pregnancy is associated with other factors and may occur with apparently normal  Fallopian tube More Detailss.

We present 36 cases of tubal ectopic pregnancies with atypical presentation in which diagnosis was initially missed by attending physician. But after thorough investigation, we could diagnose and intervene thereby reducing serious maternal morbidity and mortality.

Aim

To study the atypical presentation of ectopic pregnancies.

Objectives

To study the incidence of ectopic pregnancies

To study the variable presentation of ectopic pregnancies

To study various diagnostic methods and management of ectopic pregnancies

To study the outcome of ectopic pregnancies


  Methods Top


This is a retrospective observational study with a study population of 36 patients with tubal ectopic pregnancies presenting atypically in a total 100 (1.8%) ectopic pregnancies out of 5400 deliveries done in department of obstetrics and gynecology in rural tertiary center. Study period is four years (January 2016 to February 2020).

Case sheets are collected from medical records and emergency register are studied. Statistical analysis was done by descriptive analysis.


  Results Top


Out of 5400 deliveries, 100 were tubal ectopic pregnancies (2%) of which 36 cases presented with atypical presentation (36%).










  Discussion Top


These two cases [Table 1] were referred from outside hospital and both cases were seen by general physician and initial treatment was given. Then referred to our hospital where cases are seen by obstetrician. Probably both cases were misdiagnosed as both were unmarried and denied history of amenorrhea or contact and so urine pregnancy test (UPT) and transvaginal ultrasound (TVS) was not done but only transvaginal ultrasound (TAS) was done where they couldn't find anything. We did urine pregnancy test (UPT) which was positive and repeat detailed TAS wherein we suspected ectopic when hemoperitoneum was present and managed appropriately. The most reliable sign of ectopic pregnancy is the visualization of an extra uterine gestation, but this is not seen in 15 to 35% of ectopic pregnancies.[6]
Table 1: Ectopic Pregnancy Presenting as Severe Menorrhagia With Severe Anemia

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These two cases [Table 2] were initially seen by general surgeon and were diagnosed as severe acute intestinal obstruction and treated accordingly. Then were referred to gynecology department. They missed a diagnosis probably because there was no amenorrhea which is one of the classical symptom triad and both clinical and scan findings pointed towards bowel pathology. Due to lack of awareness of atypical symptoms, diagnosis was missed in view of history of abdomen distention with pain abdomen with constipation. When we did UPT, it was positive and paracentesis and culdocentesis were positive for hemoperitoneum.
Table 2: Ectopic Pregnancy Presenting as Pain Abdomen With Distension

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In all cases [Table 3] UPT was weak positive, free fluid in pouch od Douglas (POD) is seen on ultrasonography (USG). The most reliable sign of ectopic pregnancy is visualization of extrauterine gestation, but this is not seen in 15 to 35% of ectopic pregnancies.[6]
Table 3: Ectopic Pregnancy Presenting as Myalgia

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Approximately 1% ectopic pregnancies have a negative UPT and serum beta hCG of 20 mIU/ml. The attending physician must remain cognizant of this potential diagnosis in the setting of unexplained intrabdominal hemorrhage or severe pelvic pain with negative UPT. [7,8]

As all cases [Table 4] had regular menstrual cycles, with pain in secretary phase of menstrual cycle, corpus luteal hemorrhage was suspected. But UPT and beta hCG was positive. TAS- echogenic fluid in POD. So, laparoscopy done, tubal ectopic pregnancy was seen.
Table 4: Ectopic Pregnancy Presenting as Pain Abdomen With Regular Cycles

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The classical presentation of ectopic pregnancy is with pain abdomen and bleeding. In practice, these symptoms are not necessarily severe; often there may be only mild pelvic pain and spotting in early pregnancy (five to nine weeks of amenorrhea).[9]

These cases [Table 5] suggest that any women in reproductive age group if misses her period, UPT has to be done as early as possible. If found to be UPT positive they have to be scanned for not only confirmation of intrauterine pregnancy but also to rule out ectopic pregnancy. In all these six cases, UPT was done by patient at home and they did not visit doctor for confirmation by scan.
Table 5: Ectopic Pregnancy Presenting as Pain Abdomen With Spotting P/V in Early Pregnancy

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These cases [Table 6] suggest pain abdomen with or without fainting attack even with regular menstrual cycles has to be investigated though the causes like urinary tract infection (UTI) are anticipated in early months of marriage.
Table 6: Ectopic Pregnancy Presenting as Pain Abdomen With Fainting Attack

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These fivr cases [Table 7] presented with history of recurrent pain abdomen. Initially treated as chronic PID as UPT and beta hCG was negative with tuboovarian mass and bulky uterus on TVS.
Table 7: Ectopic Pregnancy Imitating Chronic PID

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2 of them are admitted after one month with recurrent pain abdomen on day seven or eight of menstrual cycle and UPT was weak positive but beta hCG was negative and there is mass seen on USG. They were diagnosed as ectopic on laparoscopy.

Our case findings correlate with study by Daniilidis A, et al.[10] rarely the urinary and or serum beta hCG will be negative despite an ectopic pregnancy.

These are four cases [Table 8] with IUCD insitu with history of irregular cycles, UPT and beta hCG positive and echogenic mass in two cases and echogenic fluid in POD and tuboovarian (TO) mass with fluid in POD in other cases Ectopic pregnancy is seen in 0.2 per 1000 women year in scopper T and levonorgestrel IUCD insitu.
Table 8: Ectopic Pregnancy With IUCD Insitu

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The above case [Table 9] is multigravida with BOH with two months of amenorrhea with previous history of ectopic pregnancy with PUL. This is followed up with serial beta hCG and TVS. Right tubal ectopic was diagnosed. This case suggests that even with negative sonographic findings, follow up with serum beta hCG and TVS in presence of risk factors is must.
Table 9: Ectopic Pregnancy With Bad Obstetric History (BOH)

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In patient with negative sonographic examination and positive beta hCG, about 5 to 20% ectopic pregnancies can be detected on repeat USG examination.


  Conclusion Top


In our study, diagnosis was missed not only by physician and surgeon but also by obstetrician who are primary doctors of the subject. This explains the notoriousness of the ectopic pregnancy and so any reproductive age women even without any risk factors when present atypically has to be suspected for the probable diagnosis of ectopic pregnancy and so has to be meticulously investigated and followed up. This single step may prevent morbidity and mortality.

Ethical approval

The study was approved by ethical committee of the institute.

Acknowledgements

We thank department of medical records for providing us data related to patients to publish the article. We thank stenographer in department of obstetrics and gynecology for the technical support. We also thank statistician of our institute for the support.

Financial support and sponsorship

  1. Department of medical records, Dr. Pinnamaneni institute of medical sciences, Chinoutpally, Vijayawada, Andhra Pradesh, India
  2. Stenographer in department of obstetrics and gynecology, Dr. Pinnamaneni institute of medical sciences, Chinoutpally, Vijayawada for the technical support
  3. Statistician, Dr. Pinnamaneni institute of medical sciences, Chinoutpally, Vijayawada for the technical support.


Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mahhoob U, Masher SH. Management of ectopic pregnancy, a two-year study. J Ayub Med Coll Abbottabad 2006;18:34-7. 2006;18:34-7.  Back to cited text no. 1
    
2.
Surette AM, Dunham SM. Early pregnancy risks. In: De Cherney AH, et al. editors. Current Diagnosis and Treatment Obstetrics and Gynecology. 11th ed. New York: Mc Graw Hill; 2013. p. 234-49.  Back to cited text no. 2
    
3.
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Parturition. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong, CY, Eds., Williams Obstetrics, 23rd Edition, McGraw-Hill, New York, 2010. p.143..  Back to cited text no. 3
    
4.
Arora R, Rathore AM, Habeebullah S. Oumachigui A. Ectopic pregnancy changing trends. J Indian Med Assoc 1998;96:53-4, 57.  Back to cited text no. 4
    
5.
Gaskins AJ, Missmer SA, Rich-Edwards JW, Williams PL, Souter I, Chavuro JE. Demographic, lifestyle and reproductive risk factors for ectopic pregnancy. Fert Steril 2018;110:1328-37.  Back to cited text no. 5
    
6.
Levine D. Ectopic pregnancy. Radiology 2007;245:385-97.  Back to cited text no. 6
    
7.
Mukul LV, Teal SB. Concurrent management of ectopic pregnancy. Obstet Gynecol Clin North Am 2007;34:403-19.  Back to cited text no. 7
    
8.
Pabon DF, Faun SA, Ford DT. Hemorrhagic shock from an ectopic pregnant in a patient with negative urine pregnancy test. Am Surg 2011;77:241-2.  Back to cited text no. 8
    
9.
Lin EP, Bhatt S, Dogra VS. Diagnostic clue to ectopic pregnancy. Radiodiagnosis 2008;28:1661-71.  Back to cited text no. 9
    
10.
Daniilidis A, Pantelis A, Makris V, Balaouras D, Vrachnis N. A unique case of ruptured ectopic pregnancy in a patient with negative pregnancy test. A case report and brief review of literature. Hippokratia 2015;18:282-4.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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