8


Pregnancy problems – think beyond asphyxia


Sara Williams highlights two obstetric cases where doctors faced diagnostic challenges during the early stages of pregnancy


arly-stage pregnancy is a diagnostic minefield for clinicians. Ectopic pregnancy is a leading cause of maternal mortality in the first trimester, and claims that arise out of the failure to detect a genetic abnormality can be amongst the most expensive. Case 1 highlights the difficulty in diagnosing an ectopic pregnancy even with the knowledge that the patient is pregnant. Likened to a black cat in the dark, ectopic pregnancies are notoriously difficult to diagnose. The case also demonstrates that a diagnosis of ectopic pregnancy should be considered whenever one is assessing a female of reproductive years with abdominal symptoms. Case 2 follows the story of a GP who chose not to screen his patient for Down’s syndrome for fear of it causing her to miscarry her fourth child. The case highlights why patients should be informed of the risks of screening for genetic disorders, enabling them to make informed choices about their pregnancy.


E


Ectopic pregnancy All ectopic pregnancies are silent or asymptomatic in their early phases; the problem lies in that the earlier that you catch them the better the patient’s reproductive prognosis. In a young woman in her reproductive years who presents with abdominal pain and amenorrhoea, ectopic


pregnancy should be considered and a pregnancy test carried out. Diagnosing an ectopic pregnancy can be greatly assisted by a transvaginal ultrasound; particularly if it shows a gestational sac inside a fallopian tube (see Table 1). This will normally visualise an intrauterine sac in and around five weeks gestation (see the Royal College of Obstetricians and Gynaecologists’ (RCOG) Green- top guidance with respect to the management on early pregnancy loss).1 Prominent fertility expert and


Professor of Obstetrics and Gynecology at the University of South Wales Dr William Ledger advises: “The risk factors for ectopic pregnancy are well known and features such as a history of pelvic inflammatory disease, tubal surgery (including reversal of sterilisation), in vitro fertilisation, known pelvic adhesions, previous ectopic pregnancy, etc, should be sought, but such features will only be identified in about half of all cases. Equally, symptoms may be ‘barn door’, with vaginal bleeding, lateralising pain with shoulder tip pain, and a positive pregnancy test, or they may be subtle or practically non-existent. “Early pregnancy ultrasound is commonly performed for ‘soft’ indications where there is no medical need for an early scan, but the woman wants to see the fetal activity and be reassured that all is well. An increasing number of ectopic pregnancies are


Table 1 – Diagnosis of asymptomatic tubal ectopic pregnancy, Canadian Society of Obstetrics and Gynaecology2


Possible ectopic pregnancy Probable ectopic pregnancy


Serum beta-hCG level > 1500 mlU/ml Absence of intrauterine pregnancy on transvaginal ultrasound


Serum beta-hCG level > 1500 mlU/ml Absence of intrauterine pregnancy on transvaginal ultrasound Adnexal mass on transvaginal ultrasound


Diagnosis of ectopic pregnancy Gestational sac inside fallopian tube on transvaginal ultrasound


being diagnosed opportunistically in this way. Early diagnosis may allow for use of medical or conservative tubal surgery, with the possibility of improving the chances of saving the fallopian tube.”


Wrongful life If a child is born with a severe congenital disability the child can make a claim for wrongful life, while the parents can sue for wrongful birth.3


The key issue in these cases is whether a doctor should bear the cost of raising and maintaining a child where birth was a consequence of medical negligence, eg, where the parents were not warned that their child may be born with a disability and, if they had been warned, they may have terminated the pregnancy.


A high index of suspicion Mainstays of practising early pregnancy medicine require a high index of suspicion: people can and do die from ectopic pregnancy and thousands of children are born with undiagnosed genetic abnormalities. Comprehensive examination and investigation in women of child-bearing age with abdominal or gynaecological problems is essential. Pregnancy should always be considered in the differential diagnosis as the consequences of an undiagnosed pregnancy can be catastrophic.


Thanks to Dr Graham Howarth and Dr Sonya McCullough for their help with this feature.


REFERENCES 1. RCOG, Early Pregnancy Loss, Management (Green-top 25)


2. Morin L. Ultrasound Evaluation of First Trimester Pregnancy Complications, JOGC, SOGC Clinical Practice Guidelines (No 161, June 2005)


3. Earle M, Medical Law, Dundee University Press (2007)


4. NICE, 1.7.2 Screening for Downs, Antenatal Care (2008)


IMAGE: WEBPHOTOGRAPHEER/ISTOCKPHOTO.COM


ARTICLE


UNITED KINGDOM CASEBOOK | VOLUME 20 | ISSUE 1 | JANUARY 2012 www.mps.org.uk


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28