Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Ectopic Pregnancy

Evaluate breaches in the standard of care when determining whether or not there has been a Failure to Diagnose & Delay in Treatment of Acute Abdomen Due to Ectopic Pregnancy

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the following signs and symptoms did the patient present? (Choose all that apply)
    Amenorrhea/Abnormal vaginal bleeding
    Abdominal/Shoulder Pain
    Lightheadedness/Syncope/Dizziness
    Orthostatic hypotension
    Rebound/Guarding/Hypoactive bowel sounds
    Tachycardia (increased heart rate)/Hypotension
    Abdominal tenderness
    Adnexal tenderness/Mass
    Cervical excitation
    None of the above
    Not elicited
    Answer unknown
    Why is this important?
    Ectopic pregnancy should be suspected in any woman of reproductive age who presents with amenorrhea associated with abdominal pain and vaginal bleeding. Normal pregnancy symptoms like breast tenderness, frequent urination, and nausea may also be experienced. Amenorrhea occurs in 85 percent of cases and most ectopic pregnancies present between 6 and 8 weeks after a missed period. Pain may be pelvic or abdominal; may be present in only 30 percent of cases if the ectopic is unruptured and in 97 percent to 100 percent in cases of ruptured ectopics. Vaginal bleeding may initially be light or spotting but may become heavier. Syncope, dizziness, and orthostatic hypotension may be signs of impending shock associated with rupture.
    (2012) 206 ESAJOG 4 289-299

  • With which of the following risk factors did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
A risk factor is a variable that has a causal association with a disease or disease process; the presence of the variable in an individual or a population is associated with an increased risk of the presence or future development of the disease. Thus, risk factors may be useful for identifying subjects at increased risk for a disease or for a particular outcome that results from a disease process.

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  • Was a medical history obtained? Why is this important?
    Answer this question
    
A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's examination, enables the clinician to make educated evaluations, and be better equipped to advise the patient. 

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  • Was a physical examination performed? Why is this important?
    Answer this question
    
A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. 

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  • Was the diagnosis of ectopic pregnancy overlooked in a patient of reproductive age with non-specific symptoms? Why is this important?
    Answer this question
    
A high index of suspicion is necessary if a woman of reproductive age presents with abdominal pain and vaginal bleeding and work up should be done to rule out ectopic pregnancy. Numerous conditions may have a presentation similar to an extra-uterine pregnancy. The most common of these are kidney stones, appendicitis, pelvic inflammatory disease, and urinary tract infection. The diagnosis is usually obvious for women with the classic symptoms of ruptured ectopic pregnancy: a history of irregular bleeding followed by sudden onset of pain and syncope accompanied by signs of peritoneal irritation. However, before rupture the symptoms and signs are nonspecific and may also occur with other gynecologic disorders. Entities frequently confused with ectopic pregnancy include salpingitis, threatened or incomplete abortion, ruptured corpus luteum, appendicitis, dysfunctional uterine bleeding, adnexal torsion, degenerative uterine leiomyoma, and endometriosis.

    (2012) 39 EPCCOP 1 71-82 



  • Which of the following diagnostic investigations were performed? (Choose all that apply) Why is this important?
    Answer this question
    
Diagnostic testing includes high sensitivity pregnancy test, transvaginal ultrasonography, single serum measurement of HCG (Human chorionic gonadotropin), serial HCG measurement, hemoglobin test, culdocentesis. A quantitative human chorionic gonadotropin (HCG) test measures the specific level of HCG in the blood. HCG is a hormone produced during pregnancy. A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic pregnancy. 

    (2012) 39 EPCCOP 1 71-82 



  • Was the patient referred to a gynecologist? Why is this important?
    Answer this question
    
Once a diagnosis has been made, and in many cases if a diagnosis is unclear, referral to the appropriate specialists needs to be made in a timely manner. To deliver care requires a coordinated approach that allows sharing of skills and expertise. The skills of members from all professional disciplines should be utilized. 

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  • With which type of ectopic pregnancy was the patient was diagnosed? Why is this important?
    Answer this question
    
Approximately 95 percent of ectopic pregnancies occur in the ampullary or isthmic portion of the fallopian tube. 

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  • Which of the following treatment options was initiated? Why is this important?
    Answer this question
    
Ectopic pregnancy is commonly managed with medical treatment, primarily with Methotrexate. Methotrexate is 95 percent effective in carefully selected cases when used as primary treatment. Some women are not good candidates for medical therapy and undergo surgical therapy by choice or necessity. In hemodynamically stable patients, surgery should be reserved for those who have a clearly demonstrated tubal ectopic pregnancy or an adnexal mass suggestive of ectopic pregnancy seen on transvaginal ultrasonography.

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  • Which of the following indications for expectant management did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    
Many small ectopic pregnancies are known to resolve spontaneously. These issues have led to increased interest in expectant management of ectopic pregnancy. Minimally symptomatic women with declining or stable HCG levels and small adnexal masses (less than 4cm) can be safely monitored without treatment. Patients must be willing to undergo close monitoring. The benefit of expectant management is the avoidance of surgery or drugs.

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  • Were follow-up evaluations advised? Why is this important?
    Answer this question
    
Routine follow-up evaluations are necessary to offset any complications that may arise. 

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  • Was ultrasonography recommended for suspected rupture during follow-up? Why is this important?
    Answer this question
    
The increase in tubal size and vascularity in spite of the falling HCG (Human chorionic gonadotropin) level represents a healing process and should not cause concern unless the patient is clinically unstable or has persistent symptoms.

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  • With which of the following features of a therapeutic failure did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
Therapeutic failure includes persistence of the ectopic pregnancy despite conservative treatment, HCG levels either does not fall or starts to rise again during follow-up period.

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  • Which of the following complications did the patient develop? (Choose all that apply) Why is this important?
    Answer this question
    
Complications of ectopic pregnancy stem from misdiagnosis or delay in seeking medical care and the condition continues to be a major cause of morbidity and mortality in reproductive-age women.

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  • Were the complications managed? Why is this important?
    Answer this question
    
Following early recognition, it is essential for appropriate management strategies to be implemented in order to reduce significant morbidity or even mortality. 

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  • Was patient information/education provided? Why is this important?
    Answer this question
    
Patients undergoing medical management should be made aware of the early warning symptoms of rupture and advised to report immediately to an emergency department.

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  • Were follow-up evaluations advised? Why is this important?
    Answer this question
    
Routine follow-up evaluations are necessary to offset any complications that may arise.

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  • Which of the following indications for medical/therapeutic treatment with Methotrexate did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    
Medical treatment is preferred option if the patient has already undergone previous surgeries, has extensive pelvic adhesions, and has a contraindication for general anesthesia and failure of conservative laparoscopic treatment.

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  • Which of the following contraindications to Methotrexate did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    
Absolute contraindications to methotrexate include breast feeding, preexisting blood dyscrasias, known sensitivity to methotrexate, active pulmonary disease, chronic liver disease, alcoholism, laboratory evidence of immunodeficiency, renal disease, and peptic ulcer disease.

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