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CLINICAL PEARL

"A CASE WITH A TWIST"

by Tanner Colegrove, MD, FACOG

March 24, 2017

 

A 26 year old G2P1 at 24 0/7 weeks gestation presented to the emergency department with acute onset severe RLQ pain. 

Prenatal care began at 8 wks and was complicated by:

  1. Markedly elevated AFP and severe IUGR at 20 wks necessitating transfer of care to MFM
  2. Bicornuate uterus (prior pregnancy carried in left horn; current pregnancy in right horn)
  3. History of C-section at term for breech presentation
  4. Episode of mild right lower quadrant pain two weeks prior; evaluated in triage, diagnosed as round ligament pain, resolved spontaneously

Patient reported the onset of severe, “10 out of 10” RLQ abdominal pain which woke her from sleep a few hours prior to arrival. She denied vaginal bleeding, leaking of fluid, or fever. During transport from ED to L&D via wheelchair, she vomited and had an episode of syncope.  On arrival to L&D, she was awake and alert, diaphoretic, and in severe pain.  Her blood pressure, pulse and O2 saturation were normal.  Her abdomen was exquisitely tender diffusely with guarding.  A bedside US showed fetus in the uterus with heart rate 140 bpm.  Speculum exam was unremarkable, no blood or pooling noted and os closed. An IV was placed and fluids and Dilaudid were administered.  A stat CBC revealed a WBC of 16 cells/microL and Hgb at 13 g/dL. Appendicitis was high on the list of differential diagnoses given the history of RLQ pain two weeks prior and no obvious OB etiology. MFM and Gen Surgery were consulted.  MFM recommended evaluation via a CT scan but after discussion with the radiologist and surgeon an abdominal ultrasound and a non-contrast MRI were performed instead. Sonography revealed an ill-defined mass posterior to the uterus; the appendix was not visualized. MRI revealed a small amount of free fluid, an enlarged right uterine horn containing 24 wk fetus, normal appearing small left horn, and ill-defined mass posterior to the uterus--possibly bowel vs. adnexa.  Her appendix was normal.

The patient was transported back to L&D where her vital signs, the fetal heart tones, and a repeat H/H remained stable.  Her abdominal exam did not improve. Despite treatment with narcotics she was immobilized by her pain and remained diaphoretic with a rigid abdomen.  With no clear etiology but a persistently surgical abdominal exam, an emergent exploratory laparotomy was recommended.  In preparation for possible delivery of the fetus, neonatologist and pediatric team were consulted.  The patient and her family were counseled regarding outcomes in the setting of extreme prematurity and severe IUGR.  The decision to resuscitate was deferred to the neonatal team who would base that decision on the baby’s birth size and weight.  Two units PRBCs were cross matched and available.  The primary surgical team --the OB hospitalist and an OB/GYN generalist—was assembled.  The neonatal team prepared a main OR room for delivery, and a general surgeon was available on standby. 

Intraoperatively, the patient was found to have 1.5 L hemoperitoneum, torsion and rupture of an ischemic and necrotic enlarged right uterine horn (containing the pregnancy) and adjacent adnexa. The right adnexa was adherent to the posterior wall of the uterus explaining the findings on US and MRI.  A 3 cm rent in the inferior-lateral aspect of the right uterine horn near the torsion site was noted. The left uterine horn and appendix were both normal.  A hysterotomy was made in the fundus of the right horn and a live male fetus was delivered weighing 338 gm with heart rate 70 and APGAR scores of 1 and 1 respectively. The decision to not attempt resuscitation was straightforward.  The neonate expired at 40 minutes of life. The hemoperitoneum was evacuated and the ischemic right horn was amputated and the base was oversewn.  The left horn and adnexa were intact.  An appendectomy was performed by the general surgeon. Estimated blood loss was 1.5 L and she was transfused 2 units PRBCs. The patient tolerated the procedure well.

Clinical Pearl:  “Treat the patient, not the numbers.”

The patient’s vital signs, labs, and imaging studies were unremarkable throughout the initial evaluation but were not consistent with her presentation of severe, unrelenting pain and distress.  With an abundance of sophisticated lab and imaging tests at our disposal, it is often easy to place more merit in ancillary tests than in our physical exam findings and even more tempting to be reassured by normal results.  In this case however, the astute team avoided these pitfalls, treated the patient and not the numbers, and maintained a high index of suspicion. In so doing, they coordinated a complex, multidisciplinary care plan in a step-wise, timely manner, efficiently recruited all of the appropriate personnel, and avoided a delay in diagnosis that could have had a catastrophic result for the patient.

 

Tanner Colegrove, MD is medical director of an OB hospitalist program in Illinois.  She is currently on the Board of Directors for SOGH and serves as the organization’s president elect.