Case Study

Patient A is a woman, 24 years of age, gravida three para two, who reported she believes she is about seven weeks pregnant. Three days previous, she noted some pink vaginal spotting. She presented with painless, dark red vaginal spotting. Patient A reported her last intercourse was more than a week ago. She denied any itching, burning, or malodorous discharge prior to the onset of her symptoms. She denied fever but thinks she had been having chills. Some nausea was reported but no vomiting. She did have a positive home pregnancy test one month ago. She denied uterine cramping, but admitted to some mild upper abdominal cramping. The patient complained of suprapubic pain after urination. The pain occurred after each voiding. The pain did not localize elsewhere and lasted for just a few minutes. Patient A reported some frequency, but attributed this to her pregnancy. Bowel function has been normal. She was appropriately concerned, as her previous pregnancies were uncomplicated. During the previous six months, Patient A has been diagnosed and treated for gonorrhea once and chlamydia twice. Follow-up testing was negative. Patient A has also been treated for recurrent lower urinary tract infection and bacterial vaginosis during the same period of time.

The differential diagnosis for Patient A includes:

Examination revealed normal external genitalia. The vagina was pink with moderate amounts of maroon-colored watery discharge noted. The cervix was pink and appeared closed. No exudate or lesions were noted on the cervix. Cultures for gonorrhea and chlamydia were obtained. Bimanual examination revealed a nontender uterus, anteverted, enlarged to a six- to seven-week gestational size. No masses were appreciated. The uterus was normal shape and configuration. The cervix was long and closed. Cervical motion tenderness was absent. Adnexa were slightly tender to palpation, without mass. Rectal examination was confirmatory.

Urinalysis in the office revealed 10 to 20 WBCs per high-powered field, 20 to 30 RBCs, no bacteria, moderate epithelial cells, and some casts. A urine sample was forwarded to the lab for culture and sensitivity. The routine pregnancy laboratory tests were obtained, and an ultrasound exam was ordered.

Laboratory findings revealed that Patient A is Rh negative with a negative antibody screen. She was offered RhoGAM per protocol and accepted. Her hemoglobin was 12.4, with the remainder of her lab work within normal limits. Her quantitative beta hCG was 14,283 mIU/mL. With an hCG that high, one would expect to be able to identify a fetus or products of conception on ultrasound. The radiologist immediately called to report that Patient A’s ultrasound demonstrated a thickened endometrium and a slightly enlarged uterus measuring 9 cm x 6 cm x 8 cm. No gestational sac was noted. The left adnexa revealed a significantly increased vascularity adjacent to the left ovary. The right ovary was normal, with several small follicles.

Ectopic pregnancy was suspected. The hCG levels were borderline for the administration of methotrexate. With the uncertainty of the location of the gestation and the question of the patient’s ability to return for close follow-up, the patient was prepared for surgery. At the time of diagnostic laparoscopy, a 4 cm x 5 cm cornual pregnancy was noted on the left side. The tubes and ovaries were normal bilaterally. The left cornu was removed in its entirety to the level of the endometrium; however, the endometrium was not entered.

Cornual pregnancies implant in the area where the fallopian tube enters the uterus. Approximately 1% to 5% of ectopic pregnancies occur in the cornua . The uterine muscle surrounding the cornua permits the pregnancy to grow to a more advanced age, often 12 to 16 weeks, before rupture. Because this area is so vascular, ruptured cornual pregnancies can result in a profuse, rapid, and fatal hemorrhage. This patient’s cornual pregnancy was not ruptured at the time of identification, and her postoperative recovery was normal. Urine culture done at the time of the office visit was negative. However, the chlamydia culture was positive, and the patient was treated according to CDC guidelines .

Because additional pregnancies were desired, the patient was started on hormone contraception and advised not to conceive for at least one year after her surgery in an effort to allow the uterine incision site to completely heal.

1- Explain and discuss with your classmates in 2 paragraph management and appropiate nursing interventions in this case scenario.

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