Fatal ruptured ectopic pregnancy – a case report

Introduction

An ectopic pregnancy is one in which the fertilised ovum is implanted and develops outside the normal endometrial cavity, i.e. in the fallopian tubes, cervix, ovary or in the abdominal cavity. Commonest site is the fallopian tube. About 1 in 100 to 150 pregnancies are ectopic. The risk factors are age, history of infertility, smoking, history of ectopic pregnancy, pelvic inflammatory diseases and use of intrauterine devices.^1,2

Common presenting symptoms of ectopic pregnancy are pain in the abdomen/pelvis, amenorrhoea and bleeding per vagina. Pelvic pain becomes generalised with the rupture of the tubal pregnancy. An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. Presumptive evidence is when the high resolution trans-vaginal ultrasound shows no intrauterine gestation with raised serum β-hCG.

Quick diagnosis, treating the patient for shock and emergency laparotomy would be lifesaving. The most common complication is rupture with internal bleeding that leads to shock. Death from rupture and shock is seen in women who fail to get medical help or where there is a failure of diagnosis. We report a case of a young unmarried woman who attempted to abort the pregnancy using over-the-counter (OTC) drugs from a local chemist. She died two days later from her ruptured ectopic pregnancy due to her delay in getting to a hospital.

Autopsy findings

Dead body of an adult female aged 26 years, moderately built and well nourished. Postmortem staining was present over the back and was fixed. Rigor mortis was present all over the body. Peritoneal cavity contained 900 ml of blood and 250 g of blood clot (Figures 1 and 2). Stomach contained about 100 ml of partially digested food particles. There was no unusual smell, and mucosa was normal. Uterus with cervix measured 8 cm × 5.5 cm × 3.5 cm. It was bulky with 2 cm endometrial thickness. Left fallopian tube was 5.5 cm in length, with a breach at the ampullary region measuring 1.5 cm (Figure 3). Right fallopian tube was intact. Uterus had decidualised endometrium. Histopathological examination showed a ruptured left fallopian tube and trophoblasts with foetal membrane suggestive of ectopic pregnancy (Figure 4). All other organs were intact and pale. Viscera and blood were tested negative for poisons. OPEN IN VIEWER

Figure 1.

Haemorrhage in the peritoneal cavity.

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Figure 2.

Blood clots retrieved from the peritoneal cavity.

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Figure 3.

Uterus with adnexae-ruptured left fallopian tube.

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Figure 4.

Trophoblasts with foetal membrane.

Cause of death was attributed to haemorrhage and shock as a result of rupture of ectopic tubal pregnancy.

Discussion

Ectopic pregnancy refers to the implantation of a fertilised egg in a location outside the uterine cavity, including the fallopian tubes, cervix, ovary and abdominal cavity. Abdominal pregnancies can be further classified as ‘primary’ when the implantation takes place outside the uterine adnexae or as ‘secondary’ believed to result from undetected rupture of a tubal ectopic pregnancy. ³ Ampulla of the fallopian tube is the most common site of implantation. History of pelvic inflammatory diseases and use of oral contraceptive pills are the most common risk factors associated with ectopic pregnancy. Ruptures occur even without interference by medical professionals and may be intraperitoneal when they burst through the peritoneal covering into the peritoneal cavity. An extra-peritoneal or intra-ligamentous rupture is rare, if it bursts within the lumen of the tube or in the broad ligament. In the present case, the rupture occurred intraperitoneally.

In India, ectopic pregnancy is the most common cause of maternal death in the first trimester of pregnancy. Deaths due to rupture of ectopic pregnancy constitute 0.5 to 1% of sudden natural deaths sent for medico-legal autopsy. ⁴ The incidence in the general population is estimated to be 1 in 30,000, while a rate as high as 1 in 8000 has been reported. Diagnosis requires a high index of suspicion and is often delayed. The presence of an intrauterine pregnancy, either viable or not, may actually mask the ectopic component of a heterotopic pregnancy, resulting in delayed diagnosis, but early diagnosis of a heterotopic pregnancy is difficult; β-hCG alone is not helpful. The intrauterine pregnancy masks any underlying β-hCG changes from the extra-uterine pregnancy and vice versa. ⁵

In a study, 16 (0.8%) patients were diagnosed to have ectopic pregnancy based on vaginal ultrasound findings. Most (14/16, 87%) of the patients were in second gravida or above. One patient was undergoing treatment for primary infertility. One patient had a history of ectopic pregnancy. Serum levels of β-hCG in women with suspected ectopic pregnancy were less than 700 mIU/ml in four patients (25%), 700–1500 mIU/ml in five patients (31.25%) and more than 1500 mIU/ml in seven patients (43.75%). Out of 16 cases, 10 (62.5%) cases were suspected clinically as ectopic pregnancy. Clinical features suggestive of menorrhagia, threatened abortion and pelvic inflammatory disease were present in five, three and three cases, respectively. One patient had a clinical diagnosis of acute appendicitis. History of intake of MA (mifepristone followed by misoprostol) was present in seven (43.75%) cases. All of the women were tested for pregnancy at home with commercially available kits. Five out of seven patients took the abortifacients (mifepristone followed by misoprostol) directly from a retail outlet without any prescription. Two patients did visit private doctors who prescribed them the MA. None of these patients was advised to have any pelvic USG to confirm intrauterine pregnancy before taking MA. While 4 out of 16 patients were treated medically (methotrexate), 12 cases underwent surgery. Out of 12 cases operated, eight (66.6%) had ruptured ectopic pregnancy, three tubal abortions and one chronic ectopic. ⁶

Here, the deceased had tested herself positive with a commercially available urine pregnancy test kit and then bought and used mifepristone and misoprostol from a pharmacy without consulting a doctor. She then developed acute abdominal pain and bleeding per vagina and died from haemorrhagic shock.

Trans-vaginal ultrasound should be performed in suspected cases of ectopic pregnancy when the abdominal ultrasound does not show intrauterine pregnancy and β-hCG is raised. Early diagnosis and timely management can be lifesaving in such cases. Although there are difficulties in diagnosis, women with such history should be advised by a general awareness programme to consult the doctor at the earliest time. Pharmacists should also be aware of the potential dangers when selling OTC abortifacients. Doctors should suspect ectopic pregnancy based on clinical features and should recommend trans-vaginal ultrasound with serum β-hCG (human chorionic gonadotropin) levels.

A vaginal ultrasound is highly sensitive and specific for finding of free peritoneal fluid (96% and 99%, respectively) and a tubal mass (81% and 99%, respectively). ⁷ Routine ultrasound scans can miss the diagnosis of an abdominal ectopic pregnancy in about 50% of cases. ⁸ An MRI scan may be considered the gold standard for the diagnosis of an abdominal ectopic pregnancy.

The most common causes of death in ectopic gestations in order of frequency are haemorrhage, embolism, PIH complications and infection. ⁹ In the present case, the cause of death was haemorrhagic shock.

Moreover, under section 314 of the Indian Penal Code, ¹⁰ if a pregnant woman dies from an act intended to cause miscarriage, the offender is liable to be punished with imprisonment up to 10 years even though the offender did not know or intend that his act was likely to cause death. In the present case, the deceased had bought abortion pills from a pharmacy without a prescription. Ectopic pregnancy ruptured and death occurred three days afterwards. However, deaths occurred from ectopic pregnancies even without ingestion of abortion pills thereby proving that causation may be difficult in an individual case. Yet, as it is against the law to sell such drugs OTC without a prescription, the pharmacist can be charged with an offence. Increasingly, people are able to buy prescription drugs online without any monitoring, which may result in morbidity and death.

Prompt reporting to the doctor, timely diagnosis with relevant tests like trans-vaginal ultrasound and serum β-hCG levels and quick surgical intervention will reduce the mortality in such cases.