Academic OB/GYN

As a young physician, I was taught that when a patient presents with a ruptured ectopic pregnancy and was hemodynamically unstable, the correct course was to perform a laparotomy for immediate control of the bleeding.  At that time (around the year 2000), complex laparoscopy was not really in wide practice, a
nd a physician who suggested that they could control bleeding laparoscopically as quickly as they could via laparotomy would have been met with skepticism.  In some cases, a physician suggesting a laparoscopic approach to the problem might be blocked by the atten

ding anesthesiologist, who often holds veto power over certain surgical decisions.  The idea was that the bleeding needs to be stopped quickly, and the way to do that is a laparotomy.

But over time, our ability to do things quickly and effectively via laparoscopy has changed, and I think our understanding of hemodynamic instability in young women has changed as well.

As a medical student I was taught that young women with a ruptured ectopic will be very stable hemodynamically in the face of significant blood loss until they reach a certain threshold of blood loss, then they would become increasingly tachycardia, and then eventually they would become hypotensive (low blood pressure), at which point she would be in hypovolemic shock.

The funny thing is that once I got into practice and dealt with a bunch of different situations where young women were bleeding into their abdomen, but they didn’t quite act like the textbooks said they would.

Instead of the classic stable -> tachycardia -> hypotension progression, what I saw was this: Stable with normal BP -> stable with normal BP -> intermittently low blood pressure intermixed with normal blood pressure -> eventual development of tachycardia -> finally, development of tachycardia and hypotension together.

I remember one specific case, when I was in my first year of attendinghood right out of residency, at The University of Hawai’i.   A Japanese tourist came to the emergency department with a ruptured ovarian cyst and suspicion of an ovarian torsion.  I recognized that she would need to go the OR, but because she normal pulse rate I told the operating room staff that she could afford to be put behind a few other cases that seemed more emergent, likely delaying her surgery by about two hours. Interestingly, she had a few sudden drops of blood pressure into the 80s and 90s systolic, but these seemed very short lived, almost as if they were a problem with the equipment, since within a few seconds the BP was back up to 120 systolic.  And since her pulse was normal, and teaching had been that in the absence of tachycardia she was still early in any kind of hemodynamic process, I could afford to wait a bit.

So that ended up being wrong.   I was called back to the ED when she developed persistent hypotension.  Still the pulse was only 80.  She didn’t have the tachycardia I was told to expect.  But she was persistently hypotensive.   I realized I had made an error, and called the operating room and said I needed to operate right away.   I got her in, and being taught that an unstable patient needed a laparotomy, I opened her belly and fixed the bleeding.   But I didn’t find what I thought I would.  I thought that given the level of instability she was showing, that I would find a fire hose of blood loss.  But instead I found a belly full of blood, and a very small bleeder from the edge of a ruptured ovarian cyst.  That taught me something.  She had been bleeding for a long time.  She didn’t become unstable because of a sudden increase in her bleeding, but rather the cumulative effect of slow bleeding over a long period of time.  And in contrary to my teachings, in the face of this slow bleeding she did not become tachycardic, but rather she held her pulse and lost her ability to control her blood pressure, and didn’t bump her pulse until she was profoundly unstable.

When I look back at this situation, I now realized that I managed her wrong.  Partially I was wrong in not operating fast enough, but mostly in that I was wrong about the nature of her blood loss.  Had I realized that actually her blood loss had been slow, I could have repaired that problem with fluid and blood resuscitation and stabilized her.  Once stable, I could have done a laparoscopy and prevented her from having to have a large incision in her abdomen.

And that is what is wrong with the traditional teaching about laparotomies for unstable ruptured ectopic pregnancies.   The traditional thought is that these people are so unstable that you need to stop the bleeding as soon as possible.  But the reality is that they didn’t become unstable over 5 minutes.  They became unstable over hours of bleeding.   As such, the primary issue isn’t stopping the bleeding, but rather reversing the hemodynamic effect of the blood loss.  You don’t do that with surgery, but with fluid, and if necessary, blood transfusion.   And once you have done that, the patient is stable again and now you can do a laparoscopy.

Over the 16 years I have been in practice and training, this idea has become pretty obvious to me.  But as recent as a few years ago, I still have had to convince people that an unstable ectopic pregnancy can be managed laparoscopically.

There is one caveat to this, and it is an issue of resources.  In order to rapidly do a laparoscopy on a patient who needs urgent intervention, you need a team of people who can efficiently set up a laparoscopy set.  In in that, sometimes there is a limitation.  Particularly in resource-poor care environments, sometimes it is far more efficient to do a laparotomy.  For example, I recently had a conversation with one of my colleagues in Jamaica who had taken care of a  ruptured ectopic pregnancy in the middle of the night.  I gave him some ribbing over his use of laparotomy to manage the issue, but the reality is that the problem is not his surgical skill, but rather the ability of his hospital system to rapidly set up a laparoscopy.  So there are certainly cases where laparotomy will be required.

But in the US and other fully developed nations, this should rarely be issue.  If there docs out there that are still opening unstable ruptured ectopics, think about changing what you do.  Focus on making the patient stable, and then once stable, do a laparoscopy.  The patient will be better off for it.

And if a young patient has bleeding, and she is getting intermittently hypotensive, you better act quick, because things may be further down the road than you think.

Finally, a technical tip.   If you are doing a ruptured ectopic pregnancy laparoscopically, use 10 millimiter ports for at least two access points.   In the Camera port, the 10mm lens is going to give you better visualization and is not going to fog up like a 5mm lens will, and you need to see well to move quickly.  Second, you need the second large port so that you can use a 10mm attachment for a suction irrigator.  The 5 mm tip will work fine for liquid blood, but big bleeding means big clots, and you will struggle to get those cleaned up through  5 millimeter suction tip.  And if you can’t get the blood out of the way, you can’t stop the bleeding.

Dr. Fogelson is a gynecologic surgeon and endometriosis specialist who practices at Northwest Endometriosis and Pelvic Surgery in Portland, OR.  Call 503-715-1377 for clinical consultation.  http://www.nwendometriosis.com