Fieldset
Pumpkins, Ectopic Pregnancy and the Natural History of Disease

Some medical problems can be notoriously difficult to diagnose early in their clinical course: ectopic pregnancy, meningitis, pulmonary embolus, pancreatic and ovarian cancer. The clinicians among you will undoubtedly want to suggest others.

Some medical problems can be notoriously difficult to diagnose early in their clinical course: ectopic pregnancy, meningitis, pulmonary embolus, pancreatic and ovarian cancer. The clinicians among you will undoubtedly want to suggest others. Even with the benefits of advanced diagnostic tools, these problems can be difficult to diagnose. Often as the disease progresses in its natural history, the diagnosis declares itself. Inevitably, the last doctor to see the patient looks like a genius. “It’s easy to diagnose a pumpkin in October, try doing it in May,” I like to remind my specialist colleagues.

In Canada, patients tend to seek medical care early, a blessing of our universal health care system. Not so in southern Sudan. Here, patients often present only in advanced stages of disease. But late presentation does not always make diagnosis easier, particularly for ‘Western’ trained physicians more familiar with seeing early disease.

In the end, the patient had a “chronic” ectopic (tubal) pregnancy. She had been sick for weeks with pain, vaginal bleeding, and a large midline mass in her lower abdomen. I had trouble making the right diagnosis, not because she presented so early but because she presented so late. In my defense, we have no ultrasound, no blood tests for pregnancy and certainly no laparoscopy. I was thrown off by the large pelvic mass, which turned out to be the ectopic pregnancy itself, made huge by repeated internal bleeding. Ultimately, the patient was transferred to Nasir for surgery, where the diagnostic mystery was solved and the patient received a successful operation. As for me, I chalked it up to experience and another lesson in humility.