Ectopic pregnancy

By Dr Lucianna

A sad twist

My husband, Dr W, was wielding the knife, ready to cut her open. Yeah, yeah… I know… I see you contort your face and I even hear the question from those who know him… but he’s a paediatrician, you say to yourself, how then was he wielding the knife? Simple question, simple answer: The University of Nairobi Medical School churns out all-round doctors. By the time a doctor graduates he’s trained to handle most cases in every discipline; be it surgical, medical, paediatric, obstetrics and gynaecology…whatever… ENT, ophthalmology, dermatology; the only thing we are not trained to handle, from head to toe, are teeth. Dentistry is a whole discipline on its own totally removed from a general doctor’s scope. Any doctor who then wants to specialise goes back to University for another 3 years for his masters degree in his chosen field. So, yes, before my husband was a paediatrician, he was a general doctor.

Now that I’ve set the records straight, can we go back to the story? Did I hear a yes? Thank you! So my husband was wielding the knife, call it scalpel, ready to cut. The woman had walked in with severe lower abdominal pain and spotting just a little blood vaginally. Were it not for the pain she probably wouldn’t have come to hospital when she did. Listen to this: a pregnant woman should never, ever ignore any bleeding no matter how slight, not even one drop! I have encountered countless women who came to hospital too late because they thought just a little blood was harmless. They ended up with serious problems. Some got miscarriage, losing a baby that would probably have been saved; but that’s a story for another day. Today we are talking about ectopic pregnancy.

Dr W was on call when this woman came in. He quickly examined her and established that she had an ectopic pregnancy that was about to rapture. What’s an ectopic pregnancy? Let’s go into a bit of biology. The uterus is a gourd-shaped organ hiding snugly in the pelvis of a woman. Its normal position is “bottom-up” and “neck-down”. The neck opens into a muscular tube. The layman calls this tube birth canal but there’s no shame in me calling it by its biological name, vagina. To the rounded part of the gourd, are attached two tubes one on the right and one on the left. The tubes bring eggs from the ovaries. So far are we together? Can you picture it? An upside down gourd with tubes bringing eggs from the ovaries? Faithfully, every month, one of the ovaries releases an egg and the tube on that side brings it to the uterus. If there are no sperms in the system, the egg is flushed out by the frustrated bloody tears of a sad uterus… menstruation.

If the egg encounters sperms on its march to the uterus, it is fertilised. It starts multiplying in the tube. It then happily continues on its journey, only this time not just as a plain egg, but as the beginnings of a baby. Merrily, merrily, merrily, merrily, down the tube it goes! The journey takes about 8 days and upon arrival the baby attaches itself to the uterus and continues to grow. This time, and for the next nine months, no sad uterine tears are shed. The uterus expands to accomodate the baby. But sometimes, by an accident of nature or disease, the baby doesn’t go all the way to the uterus. It attaches itself to the tube. It starts growing inside the tube. The tube expands a little to accomodate the baby but by around 8 weeks it can expand no more. It then bursts! Raptures! The bleeding that results is terrible… It’s massive… It can kill… It has been known to kill!! Ectopic pregnancy means a pregnancy in the wrong place, usually in the tube. It could be anywhere.

Immediately Dr W diagnosed ectopic pregnancy he planned for surgery and had the woman rushed to theatre. An ectopic pregnancy is a dire emergency because the mother can bleed to death if immediate action is not taken. If you were ever next on the theatre waiting list and you were told, “sorry, we have an emergency”, it was probably an ectopic pregnancy. In my practicing life I have seen many patients get frustrated because they thought we had been bribed to bump them off the theatre list. Sometimes there isn’t enough time to explain and even when we do explain we are bound by ethical considerations. So we just tell them we have an emergency that can’t wait and must skip the queue.

Dr W made the cut, opened the abdomen and proceeded with his surgery. He identified the offending tube. It had actually raptured and was bleeding profusely. He tied it, then cut it and then arrested the bleeders. When a tube is tied and cut, it is no longer able to carry eggs. So the woman is left to function with only one tube. She is still able to get pregnant. Most women will not even feel the difference between one tube and two tubes. They get their normal monthly periods. As Doc was wiping away the blood and trying to clean up the woman, he realised that there was still a bleeder somewhere that had not been arrested.

He swabbed again and held it up to look more closely. That’s when he realised the bleeding was coming from somewhere else. He meticulously inspected the area and followed the blood flow to see where it was coming from. And oh my God!! It was coming from the other tube!! Another ectopic!! He tied… and cut… and arrested the bleeding… and repaired the abdomen. What are the chances that one can get a double tubal ectopic pregnancy?? Studies show 5 in a million! God! I feel this mother’s pain. She had conceived twins, one from each ovary, and each got stuck in the tubes! Both raptured! The tragedy was, her fate was sealed. She could not ever again have a natural conception. With advances in science, she can have in-vitro fertilization, test-tube baby, but it’s extremely expensive. Given that she was in a public hospital, what are her chances of affording it? I asked my husband if she had other kids but he couldn’t remember. It was a long, long time ago.

Such things make doctors feel so helpless, so inadequate. But most of all, they remind us that we are not gods. We are simply human, but with a special gift.