Seriously?!

If you ask me what I like the best about doing Ob/GYN, I usually say: "The unpredictability."

Today I was a victim of my own cliche answer.

We admitted Susan to the ward ~ 1 week ago.  She came to Casualty complaining of a low abdominal pain and an ultrasound from an outside clinic citing a pelvic abscess.  She said the problem started four weeks prior after a d&c at a nearby hospital for a miscarriage.  She complained of pain, but no bleeding or vaginal discharge. 

She was afebrile.  Her white count was normal, Hb was 13 and her pregnancy was negative.  I repeated an ultrasound at our facility: there was a thickened stripe in the uterus and a large mass in the pouch of douglas consistent with an abscess.

So, I thought, great - this poor lady had a miscarriage, somebody did a d&c and perforated her uterus and now she has an abcess and maybe retained products!

We get alot of chronically botched abortions/retained products here in Kenya.  Because of the high rates of infection and sepsis, if the patient is stable and no signs of SIRS, I prefer to get 24 hours of antibiotics in before a d&c.  For pelvic abscessed related to PID, I usually try 48 hours of IV antibiotics before turning to ex lap - there's a lot of pelvic TB and PID here, so ex lap is not also a successful option for those desiring fertility.

For Susan, I decided to start with a d&c and Culdocentesis.  During the d&c, I discovered that her cervix was very stenotic and upon dilatation, a fair amount of old blood poured out!  I was surprised!  The person who performed the d&c had perf'd her uterus AND injured her cervix to the point of stenosis, causing pyometrium.  Complicated!  On my culdocentesis, I got no return: no clear fluid, no blood, no pus - nada.  Weird, I thought.

Anyway, the next day Susan felt better.  She had a discharge now, but overall she was happy.  Great!  I thought.  Now, we will just continue the antibiotics.

Post op day 2: Susan felt worse again with pelvic pain and vomitting.  Another ultrasound showed the abcess just as before, now with a normal uterus.  Still she was afebrile.  We discussed what to do.  She wasn't too keen on the idea of an exploratory laporatomy, so we decided to try the culdoscentesis once more.

Still nada on the culdocentesis.  I was starting to feel like a culdocentesis-failure.  Moreover, I felt like it was time to throw in the towel and just go to the OR.  My Kenyan colleague helped convince Susan of the same.

Today we did the ex lap.  I could not believe it.  We opened up her abdomen and there in the stupid pouch of Douglas was 350 mL of old, clotted blood (I'm NOT a culdosentesis failure!).  Her left tube was dilated to 4 cm distally with old clot spilling out.  It was adherent to the posterior side of the uterus and into the POD. 

It was a CHRONIC ruptured ectopic!  If you had asked me about such a thing last week...I wwould have said such a thing could never exist!  But it can in Kenya!  SO, the guy at the other hospital DIDN'T perf her uterus during the d&c, he just MISDIAGNOSED an ectopic pregnancy! 

Meanwhile.....I came along....un-stenosised her cervix from the unnecessary d&c, drained her pyometrium, did two unnecessary culdocentesises, all in the face of a NEGATIVE pregnancy test and Hb of 13!

Seriously?! 

Susan, the woman who survived a chronic ruptured ectopic pregnancy...

This job is crazy.