Case Study
We received a priority 2 call Code 20 for a 35-year-old female with abdominal pain and dizziness. The CAD data was as per below
YOU ARE RESPONDING TO A 35-YEAR-OLD, FEMALE, CONSCIOUS, BREATHING. ABDOMINAL PAIN / PROBLEMS CODE: 1-C-4: FEMALES WITH FAINTING OR NEAR FAINTING 12-50 CALLER STATEMENT: WIFE HAVING STOMACH PAINS.
On our arrival we were met by the patient’s husband and taken to the patient lying supine in bed, alert to our arrival. The patient was visibly pale, complaining of 2/10 pain in the suprapubic region coupled with mild nausea.
History of presenting complaint
The patient reported she felt well today and attended normal work duties as a healthcare assistant. Approximately two hours before the ambulance call, the patient was reporting sudden onset of burning 2/10 suprapubic pain radiating to all regions of the abdomen. This was accompanied by nausea and a pressure and urge to open her bowels, however she denied recent changes to her bowel habits, urinary symptoms and vomiting.
The patient had been in recent contact with her toddler who was recovering from gastroenteritis and had initially attributed her symptoms to the same.
The patient denied the prospect of pregnancy due to the reported use of contraception, though the specific type of contraception and overall compliance was not queried. The patient was on day 2 of menstrual cycle and reported some PV bleeding consistent with menses as expected, however since using emergency contraception (the morning after pill) 5 weeks ago following unprotected sex, she reported recent intermenstrual bleeding.
It was not until she developed severe dizziness on ambulation that the ambulance call was initiated.
Past Medical/Surgical History
- G3P2 – 1x miscarriage, 2x term deliveries
Medications
- Nil
Allergies
- NKDA
On Examination
Initial observations
- Respiratory rate: 18/min
- Oxygen saturations 99% RA
- No palpable radial pulse. Brachial pulse 100
- Blood pressure 80/55 (MAP 63) on auscultation
- GCS 15 (although lethargic)
- BGL 11.4
- Afebrile 36.0°
- ECG: Sinus rhythm
Abdomen soft with lower abdominal tenderness and guarding but no obvious mass or rebound tenderness. Bowel sounds present. Patient unable to sit up from supine without unpleasant pre-syncopal sensation and thus required extrication via carry canvas.
Initial treatment
- 18-gauge intravenous (IV) cannula inserted in right anterior cubital fossa
- Bloods taken
- IV ondansetron administered for mild nausea
- 250ml bolus of normal saline 0.9% commenced for hypotension
- Considered analgesia but patient refused
Differential Diagnosis
Whilst the patient displays none of the main risk factors in her past medical history, the following key signs and symptoms are suggestive of ectopic pregnancy;
- Abdominal pain in a woman of reproductive age
- Vaginal bleeding (though most ectopic pregnancies exhibit pain and nil/minimal bleeding)
- Pre-syncopal episodes
- Recent unprotected sex
- >5 weeks since last normal menstrual period
- Hypovolaemic shock
A potential diagnosis of ectopic pregnancy was formed; IV fluid administration was ceased in line with permissive hypotension protocol and King Edward Memorial Hospital (KEMH) Emergency Department (ED) was contacted for consultation. A plan was formed for urgent transfer of the patient to Fiona Stanley Hospital (FSH) due to proximity and suitability.
During the transfer, the patient’s haemodynamic stability was closely monitored with blood pressure and pulse remaining 95/60 (MAP 72) and 100 respectively. The patient’s colour, nausea and general malaise also slightly improved whilst supine on the stretcher.
At FSH ED, the patient was triaged category 2 for suspected ruptured ectopic pregnancy and was prepared for surgery shortly after examination by the medical team
Summary
Paramedics should consider ectopic pregnancy in all women of reproductive age who are presenting with abdominal pain.
Women using contraception (including emergency contraception) are at a very low risk of pregnancy, however if they do conceive, the probability of an ectopic pregnancy is high.
Mismanaging the care of women with ectopic pregnancies is easier than making the correct diagnosis, partly because cases present infrequently, but mainly due to presentation not always being classical. A systematic approach to history taking, including the use of both open ended and direct questions is important to allow for proper evaluation and patient management.
References
Barnhar, K. T. (2018). Ectopic pregnancy. BMJ Best Practice. Advance online publication. https://bestpractice-bmj-com.ipacez.nd.edu.au/topics/en- gb/174/pdf/174/Ectopic%20pregnancy.pdf
Curtis, K., & Ramsden, C. (2016). Emergency and trauma care for nurses and paramedics (2nd ed.). Chatswood, NSW: Elsevier Australia
Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. (2012). National Institute for Health and Clinical Excellence. Retrieved May 17, 2020, from https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s Health/Statement and guidelines/Clinical - Gynaecology/NICE-Ectopic-pregnancy-and-miscarriage.pdf
Government of Western Australia North Metropolitan Health Service- Women and Newborn Health Service, 2020. Pregnancy: First Trimester Complications. Obstetrics and Gynaecology Directorate. Retrieved from https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For health professionals/Clinical guidelines/OG/WNHS.OG.PregnancyFirstTrimester.pdf
Tulandi, T. (2020). Ectopic pregnancy: Clinical manifestation and diagnosis. Topic 5487 (46), UpToDate. Retrieved May 17, 2020, from https://www-uptodate-com.ipacez.nd.edu.au/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis
Page contributors:
Kadogan Combes, AP20831
Ambulance Paramedic, Metropolitan Ambulance Service
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