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An aside is warranted before I continue my story… The superstitious amongst us health care workers know that bad things occur in threes. Some weeks ago, a friend advised people not to name a disease, lest it occur. I guess I have to add a supplement - Don’t read about a disease in a blog. It will occur in your practice.

The first was a lady in her early thirties who went to her Gynecologist with complaints of mild lower abdominal pain. The Gynec found a boggy fullness in the adnexa with mild tenderness on the pelvic exam. So an ultrasound scan was asked for.

On the abdominal ultrasound, I found what looked like an organized blood clot in the rectovaginal pouch. This was confirmed on transvaginal ultrasound. There was approximately 250 to 300 cc of clotted blood in the rectovaginal pouch.

Additionally, the left adnexa showed an irregular ectopic gestational sac of about 6 weeks size with a yolk sac inside.

The diagnosis was obvious - a ruptured tubal ectopic.

Surprisingly, this lady was clinically very stable. I wondered why the diagnosis was not suspected clinically. It turns out the lady has had primary infertility for over 15 years and her menstrual periods are very irregular. So she or her Gynec did not suspect anything untoward.

The second case of ectopic that I saw was a forty-something lady with two grown children. She went to her Gynec (a different one) about ten days after she missed her menstrual period. The patient was not too sure if she had had unprotected intercourse, so the Gynec did a urine pregnancy test, which was faintly positive. An ultrasound scan was done (not by me), and the lady was told that she was not pregnant. About two weeks later, she had mild vaginal bleeding. The Gynec asked for another ultrasound scan (not done by me again), which was reportedly normal. The lady went back to her Gynec a week later because she was tiring easily and she had mild abdominal pain. This time her Gynec sent her to me for an ultrasound scan.

The initial abdominal scan showed some fluid in the abdominal cavity, under the Liver (Morison’s pouch) and in the pelvis.

Transvaginal ultrasound showed a lot of fluid around the uterus and the right ovary. The uterus was normal with no sign of an intrauterine pregnancy. The fluid showed small particles (fine mobile internal echoes in our parlance) which is very suggestive of either blood or pus. I also saw a small well-defined cyst in the left adnexa.

This was so soon after the previous patient (two days, in fact), that I called it a ruptured ectopic pregnancy on the left side.

Both the women were operated on. The surgeon found a ruptured gestational sac in the left adnexa in the first woman. The second lady had a ruptured tubal ectopic on the RIGHT side with a lot of blood in the abdominal cavity and a small cyst in the left ovary.

In my experience I have found that only a small proportion of ectopics present classically. Most often we stumble on the diagnosis in the course of working-up a patient with some other goal in mind.

And the most difficult to diagnose are cases of heterotopic pregnancy. These are medical rarities in which a normal intrauterine pregnancy coexists with an ectopic pregnancy.

For the pessimists, its bad news even if you are pregnant with a normal uterine pregnancy.

To end I wish to present what in my opinion is the world’s worst (or best) ectopic pregnancy.