Pain

06 April 2016

When I arrive in triage, I see a woman lying on the triage bed in tears, her face contorted in pain. The local midwife, D, is doing a transabdominal ultrasound, and Roisin and Cecile, the expat midwives, are also there. They show me what they see on the ultrasound, and it is very clear that there is a cystic structure in the abdomen on top of the empty uterus. It looks very consistent with an ectopic pregnancy, which is a pregnancy outside the uterus, usually in the tube. If it is, this is extremely dangerous—the pregnancy could rupture and she could bleed inside her abdomen, possibly to death.

The patient is writhing in pain. From what they are showing me, I am very, very concerned that she has a ruptured tube. I have Cecile repeat D’s ultrasound while I watch carefully, and it shows the same thing. She has what we call a “surgical abdomen” —she must be taken to OT based on her physical findings.

I call the anesthetist, Eileen, and update her. She has one quick case on the table that will be done soon, and she can take us next. I have the interpreter help me explain to the patient that I am worried about ectopic pregnancy, and that it can be life threatening, so it is important to get her to the OT quickly, and we obtain her consent. She starts crying even harder. Roisin, who has such a comforting, maternal presence, takes over. The patient collapses onto her shoulders and sobs hysterically. It’s quite an adorable sight, with Roisin embracing and soothing her in a sweet Scottish accent.

Once the patient is under anesthesia, we move quickly. I am doing a mini-laparotomy, which is a very small incision on the abdomen—only about 3-4 centimeters wide—because I don’t need such a large incision for this surgery. There are about 30cc of blood in her abdomen, indicating that something suspicious is going on in her pelvis. I get down to the pelvic organs and use a gentle clamp to lift her tubes. I pick up the left tube, where I expect the ectopic to be, but it’s normal, as is the ovary. Weird—the ectopic pregnancy must be on the right side; that happens sometimes. I look over on the right side and pick up the right tube: completely normal tube. What the hell?!? No ectopic pregnancy. The right ovary, however, is enlarged with multiple cysts, and clearly has one area where a cyst recently ruptured. I look around the rest of her pelvis, but don’t see the pregnancy anywhere.

So now what’s going on? There is blood in her abdomen, an enlarged ovary, and no ectopic pregnancy. I realize that I never saw the positive pregnancy test myself, so I send a nursing student to repeat the pregnancy test, and confirm with D (the local midwife) that he did do one. The repeat test is, in fact, positive, and D shows up looking ashen, in disbelief that we can’t find the ectopic. “But we saw it on the ultrasound!” he says. I agree with him, but I can’t find it anywhere.

At this point, I’m stumped and frustrated. Where is this pregnancy? I don’t want to close her abdomen without finding it. She was in excruciating pain. How can I leave her to continue screaming and writhing like that without fixing the problem? Was it just this cystic ovary that was causing all that?

Finally, I have someone bring the ultrasound, and I scrub out to do a transvaginal ultrasound and make sure I’m not missing anything, while leaving scrub tech to protect the abdominal incision, which is still open. On ultrasound, her uterus is normal, with nothing inside it. Her right ovary does look enlarged on the ultrasound, and while it doesn’t look exactly like that cystic structure we saw before, maybe that cyst ruptured and was the blood I saw when I opened her abdomen? The cystic structure is gone, and I see no ectopic pregnancy anywhere on ultrasound.

Finally, I decide that what we must have is a ruptured hemorrhagic cyst and a very early pregnancy (“pregnancy of unknown location”).  Surgically, I have done everything I can, so I close my mini-laparotomy incision. Not a very satisfying case.

The patient does well postoperatively. The next day, I explain the situation to her, and I try to frame it as a positive: “Good news! The baby might be OK.” I explain that she did not, in fact, have an ectopic, and that the pregnancy might be still growing, and that the pain was due to a cyst. She is satisfied with that explanation, and seems happy to still be pregnant. She is ready to go home after a couple of days, and I give her instructions to come in after a week to repeat the ultrasound to look for the pregnancy.

When she returns, I have Roisin, the expat midwife, do the ultrasound because she is trying to improve her ultrasound skills. We see a small yolk sac inside the uterus, confirming a 5-week pregnancy inside the uterus—a normal pregnancy. We tell her that we can see the pregnancy, and we ask M to ask her how she feels about that, especially since she seems pretty morose.

“She says it’s OK, you can get rid of it.”

Now, that’s a confusing answer.

“What? What does that mean?”

M looks as confused as we are. He talks more with her.

“She says the pregnancy is causing her too much pain, so you can get rid of it.”

We notice that the patient has gone from looking generally unhappy to crying.

“She says that the pregnancy is causing her too much pain already, it will cause her more pain when it grows.”

“Is she in pain? We fixed the pain last week with the surgery. The pregnancy is normal—it shouldn’t be causing any pain.”

“She is still having pain in her abdomen.”

The patient is full on crying now. I look at Roisin and mutter to her, “This is something social going on here.” She agrees. I sit the patient up.

“OK, let’s talk. What’s going on? Is everything OK at home?”

M inquires. “Everything is OK at home. There is no problem with the husband.”

M is an incredibly talented and sensitive midwife. I start to consider whether I should task him with talking to her alone and seeing what he can uncover, or whether I should keep prying more. I decide to ask a few more questions and if no success, I would let him try alone. I ask some details about her living situation.

She lives here in town with her husband. She has one child already, who lives in the village with her mother. I ask why the child is with the mother, and M explains that when a couple wants to have another baby, they will send the first child away to live with the grandmother so that the woman can get pregnant. In that case, it’s even more suspicious that she wanted to terminate the pregnancy if they are actively trying to get pregnant and sent her first child away for that reason.

The whole time we are talking, tears are streaming down her face, and she occasionally pauses to point to her lower abdomen and tell us about the abdominal pain she feels there, which bothers her all the time.

“I am going to ask you some questions. Are you able to sleep at night?” 

M translates for me, while the patient answers through sobs.

“No, I can’t sleep at night.”

“Do you have an appetite?”

“No, I don’t have an appetite.”

“Do you feel sad sometimes for no reason?”

“Yes, I feel sad sometimes. I am very lonely.”

“Do you cry sometimes for no reason?”

“I cry when the pain comes.”

“When your baby was living with you, were you happier?”

“Yes I was happier. Sometimes I am even quarreling with my husband all the time, and I feel very alone.”

Roisin and I make knowing eye contact.

“Can I tell you what I think the problem is?”

“OK, tell me.”

“I think that you are very sad. You miss your baby, and your mother, and you are lonely here. You are so, so sad, and that sadness has gone all the way into your abdomen, and it is giving you pain there. This is normal, it even happens to people in my country. It is not the pregnancy giving you pain, it is the sadness.”

I give her a minute to let this sink in.

Roisin pipes up. “Sometimes when people feel sad, they need their mother.”

The patient wipes the tears from her face and speaks. M translates.

“She will speak to her husband and move back to the village with her mother and her baby, and she will try to be happy.” M confers with her. “But I have told her that she should wait until Monday, so that she can go to ANC [antenatal care] to register and get ferrous sulfate and deworming.”

That’s M—always thinking ahead, thinking about optimizing their care. His tone with her has been incredibly gentle and caring. We let her breathe and calm down a little bit, and then Roisin and I leave, knowing that M will have a few more soothing words with her.

I have mixed feelings about this case. I was very angry with myself when I realized that she didn’t have an ectopic pregnancy. But thinking back on it, and speaking to my team, there wasn’t much else I could have done—she was crying in pain and had a surgical abdomen. It turns out that while she had a real reason for pain (the ruptured hemorrhagic cyst), probably her tolerance for pain was a lot lower due to her depression, and this clouded the picture. There was no way for me to know this at the time that I met her crying and writhing on the exam table, and I had to act on the information I had at the time. A positive pregnancy test, an empty uterus, and an adnexal mass adds up to an ectopic pregnancy, except that this time it didn’t. I’m not thrilled that she had a surgery for nothing, but I’m glad that she recovered very quickly, and I’m also glad that we did follow her up a week later, and that we were able to get to the bottom of what was really going on with her. So there is some satisfaction here.

You can’t cut out the problem in every case; sometimes it’s a suspicion that something doesn’t add up, a conversation, a little prying, and a shoulder to cry on.

On Monday morning, I am walking into the hospital, and I run into the patient at the entrance. In her little bit of English, she tells me she is headed to antenatal clinic. She is smiling.