01.
As soon as I took over, I was sitting in the shift room when I heard the chief hospital rush in and hurried: “The outpatient clinic will accept a missed abortion later, and the ultrasound said that it has fallen to The next paragraph, Look at the bleeding situation. If there is a lot of bleeding, we will go to the Qing Palace later. I will go to the surgery first.”
“Oh-” I moved towards the figure walking away from the general hospital and agreed.
I found a computer, opened the hospital registration system, looked through the hospital card issued by the outpatient clinic, read the name of the whereabouts, it was my junior. So he took out his phone and started asking.
“Junior brother, what happened to the missed abortion you just opened? Is there a lot of bleeding?”
“Not much. I took a urine HCG test at home a week ago and it was positive. I had some bleeding this morning, but no abdominal pain. I was worried about ectopic pregnancy, so I came to the clinic.”
“Okay, have you taken the ultrasound? Let me take a look.”
“That must be there. I also sent it to the general hospital. The blood has not yet come out. The laboratory department said it will take about an hour to get the results, and it has been expedited.”
I received the B-ultrasound, read it, and the report indicated: after 56 days of menopause, the uterus was full and enlarged, and there was no obvious abnormal echo in the muscle wall; the size of the lower uterus near the internal mouth was about 2.7 × 2.0 × 2.1 cm gestational sac echo. No germ and yolk sac echoes were seen. An irregular dark area was detected above the gestational sac, and the larger section ranged about 3.5 cm. There were no obvious abnormal echoes in bilateral adnexal areas.
Diagnostic opinion: The embryo has stopped developing, and it is located in the lower segment of the uterine cavity, 5 mm away from the internal cervical os.
02.
It doesn’t seem like much, then come in and ask for a medical history and check before making a decision.
In the end, I waited for 2 hours. I have seen a lot of emergency rooms, but I still didn’t wait until the nurse sister called me to make a doctor’s order. It was already 7 o’clock, so I called the patient’s number. The phone, the phone was connected, but it was quickly pressed again.
I don’t believe in evil, so I called another one and found that I was blacklisted.
I thought about it, maybe it’s because of my phone on duty? Looks like a scam call?
Touched the landline, and the patient finally answered the phone. “Hello? Is it XXX? This is the gynecology department of XXX hospital. Why don’t you go to the hospital? It’s been a long time since you were old.”
The other side lowered his voice and replied in a breathy voice: “Doctor, I’m watching the movie, it’s over soon, you wait for me.”
? ? ? I’m just a huge question mark, but it doesn’t look like things are in a hurry.
I finally waited for the patient to be hospitalized. When the nurse notified me, I happened to be in the emergency room, and asked the nurse to help me ask if I was feeling any discomfort and to check if the vital signs were stable. wait a second.
Finally, 4 hours after I learned of this patient, I saw this patient. It was a 23-year-old young girl, next to her accompanying boyfriend. After careful observation, his face was ruddy and he was in good spirits.
The two young couples said to us a little embarrassed: “I’m sorry doctor, we had an appointment to watch a movie today, but I didn’t expect bleeding in the morning, so we came to the hospital, but the doctor put us in the hospital. .But it just so happens that the movie is about to start. There is not a lot of bleeding, I think it should be time to watch this movie, I am really sorry to trouble you.”
I did hold back a lot of words and wanted to complain, but the other party was really kind, so he just held back my words and said, “Okay, has the information been registered on the nurse’s side? “After getting a positive answer, I took the patient to the examination room.
Vulva: normal development, vagina: moderate blood clot, no obvious damage to vaginal wall and fornix, cervix: external opening closed, active bleeding visible, moderate amount, not visible Incarcerated tissue. Uterine body: the size of 50 days of pregnancy, no tenderness, double appendages: no obvious mass.
03.
I feel like I need emergency treatment. When I see the amount of bleeding, I get a little angry, “This is a lot of bleeding, why are you still watching a movie!”
The little girl was a little surprised: “I didn’t have much before, doctor, look!” After looking at her sanitary napkin, she just finished the outpatient clinic and listened to the outpatient doctor’s advice to change it. It’s really only a little bleeding.
I discussed with the general hospital who got the news, and prepared for emergency uterine cleaning. After explaining the possible risks to the patient and the follow-up to be followed up, preparations for the operation began.
The patient had no problem with this, but asked, “Can I go to work tomorrow? I don’t want to lose the attendance bonus.”
The outstanding student has all blood routine, DIC, liver and kidney function and other related blood drawn in the outpatient clinic. The HCG is 5432 mIu/mL, and the rest of the indicators are normal.
Nurse sister also worked very hard to send the patient to a small operating room specially used for curettage, palace cleaning, abortion, etc. within 5 minutes.
When I was in the hospital and washed my hands, I pushed out the ultrasound machine, glanced at it, and shouted: “The gestational sac is really low, and it feels like it’s going to fall out. Come out, no wonder there is so much bleeding.”
Total hospitalization alsoGlancing at it, he nodded and said, “It seems to be, but it doesn’t feel too big. Size 8 is definitely enough.”
We all thought it was a very simple operation, but something happened that we didn’t expect.
04.
The total hospitalization was disinfected, and the towel was applied. The position of the uterus was reviewed by the bimanual examination, which was basically the same as that of the B-ultrasound.
In the second that the cervical grasping forceps were clamped in the general hospital and the probe probed into the uterine cavity, an accident happened!
From my point of view,just as the probe went in, a burst of blood spurted out and sprayed directly onto the inpatient’s face and neck, and it continued, In a blink of an eye, 500 mL came out.
Suddenly there was chaos in the operating room, and the general hospital immediately packed gauze to stop the bleeding. However, because there was no way to determine the bleeding point, the entire cervix could only be compressed, and the effect was very poor. A few pieces of gauze.
At the same time, the nurse opened the IV fluids immediately, and the obstetric front-line class and I, who were called to help, hurriedly called the blood bank and the interventional department to contact the blood transfusion and uterine artery embolization. He also came to the scene to organize rescue. While preparing for embolization, he also made preparations for hysterectomy.
The hospital has opened a green channel, everything is simplified, and the procedures will be filled later.
Within 5 minutes the patient was on the operating bed in the DSA operating room, and teachers from the anesthesiology, interventional and medical departments were already there.
Under the efforts of experienced interventional teachers, the uterine artery embolization was completed, and the gauze pressed on the cervix was released. The initial estimated bleeding was 1200 mL.
05.
“It’s cervical pregnancy.” The supervisor on duty took out the B-ultrasound and looked at it again, “Although the uterine artery is embolized, there is still blood supply around the gestational sac. shed from the uterine cavity.”
The two people in the hospital and I were still in shock. We realized that the two of us were too much care, and we felt that this missed abortion was too simple and common, so we relaxed our vigilance, and this happened. matter.
Actually, the gestational sac falls off to the cervical canal and cervical pregnancy. Since entering the obstetrics and gynecology specialist study, it has been reminded all the time, because it is true that seniors have also experienced such things. Unexpectedly, such a mistake still occurred despite the repeated “whiplash” of the seniors’ experience and lessons.
Why didn’t you think of cervical pregnancy? Because of the “atypicality” of the case.
Cervical pregnancy is when the fertilized egg implants and develops in the cervical canal, and it occurs mostly in multiparous women. This patient was pregnant for the first time.
Clinical manifestations of cervical pregnancy: mainly painless vaginal bleeding or bloody discharge, the amount of bleeding varies from less to more, and it can also be intermittent vaginal bleeding. A small amount of bleeding in the morning to a moderate amount of bleeding after hospitalization is consistent with the clinical manifestations of cervical pregnancy, but this alone is difficult to distinguish from inevitable miscarriage and incomplete miscarriage.
Signs of cervical pregnancy: The cervix is markedly enlarged in a barrel shape, becomes soft and blue, the external cervical os is dilated with a thin margin, the internal os is tightly closed, and the uterus is normal or slightly larger.
Later at the case discussion meeting, I, the general inpatient and outpatient students all recalled the shape of the cervix during the gynecological examination. It was a normal shape, and there were no typical signs of cervical pregnancy. , may be related to the fact that half of the gestational sac crosses the internal cervical orifice and half is still in the uterine cavity, so the physical changes of the cervix itself are not as obvious as most cervical pregnancy.
Of course, although there is “atypicality”, the main problem is that we do not consider cervical pregnancy! This is the main reason for missed diagnosis of cervical pregnancy.
What if I have a cervical pregnancy?
1. Pretreatment: preoperative MTX treatment, 20 mg × 5d intramuscular injection, or single 50 mg/O, or MTX 50 mg injected into the gestational sac.
2. Preoperative preparation: make preparations for blood transfusion before surgery. It is recommended to perform uterine artery embolization before surgery if possible.
3. Surgical plan: Under the premise of uterine artery embolization + blood transfusion, emergency surgery, and fluid replacement, cervical scraping or endocervical suction curettage is performed.
4. Precautions after operation: Use gauze or water bladder to compress the cervical canal wound after operation.
5. Postoperative hemorrhage treatment: If the bleeding persists, bilateral internal iliac artery ligation/emergency uterine artery embolization can be performed. If the effect is not satisfactory, total hysterectomy is recommended.
Actually summed up so much, self-reflection in the whole process of diagnosis and treatment, The biggest problem is that when I see this patient, I never thought of the word cervical pregnancy, >Otherwise, the blood flow window can be cut and checked during the intraoperative B-ultrasound.
All the follow-up summaries are actually just retrospective discussions. The most important and only reason is to lose vigilance. The business ability is still far behind, and more study and review are needed.
So I share this case with you. I hope that when you encounter this disease in the future, don’t forget the possibility of cervical pregnancy. After all, we have this case with a history of blood and tears.
Being a doctor, always be vigilant! Don’t ignore some very important and dangerous details because the cases are too common.
Planning: dongdong
Title image: Zhanku Hailuo