About 1 am, a 34-year-old G8 P7 woman from a remote village in Ghana experienced a sudden onset of abdominal pains, nausea, and lightheadedness. When it didn't resolve by morning, she and her relatives began walking to the nearest road to get to the District Hospital. She had received no prenatal care and had vaginally delivered her previous seven children at home without complications with the help of a traditional birth attendant. All were alive and healthy; although she did not know her oldest child's exact age, that woman now had three children of her own. The patient had never had abdominal surgery and was otherwise healthy.
Since her symptoms resolved somewhat while walking, the group stopped along the way to bathe, wash their clothes and eat. However, upon arriving at the small town, she experienced severe nausea, increased abdominal pain, and near-syncope. Her memory of subsequent events was hazy. A taxi, which her companions had to pay for in advance (she had only the government insurance provided to pregnant women, rather than the 15 Ghana Cedis ($10.70 U.S.)/year family health insurance), took her on the two-hour ride to the Kintampo Municipal (District) Hospital. She arrived at 7:10 pm.
Upon arrival, an emergency department nurse found that she had a distended, diffusely tender abdomen. (The nurse had advanced emergency medicine training through Columbia University's sidHARTe Program: www.sidHARTe.org). Her vital signs were: BP, 70/40 mm/Hg; RR, 34/min; HR, 96/min; T, 34.8 C (axillary). The nurse immediately called the local surgeon who found a very pale woman with guarding and rebound tenderness. Suspecting an ectopic pregnancy, he first did an abdominal tap, which did not yield any blood. He immediately performed an abdominal ultrasound and visualized a 17-week intrauterine fetus with a heartbeat and a large amount of intraperitoneal free fluid (Figures 1). An ultrasound-guided abdominal tap yielded non-clotting blood. Laboratory studies that had been drawn on arrival showed Hgb 7.4 g/dL; Hct 27%; WBC 11.2 X 103/microL . She was prepared for emergency surgery and entered the operating room at 8:20 pm.
Just before anesthesia induction, the patient suddenly said that she would not consent to the operation unless she could be assured that the pregnancy would be terminated. She said that she had enough children. Since the surgical staff couldn't assure her of that, she refused anesthesia until she was informed (with no hyperbole) that, without the operation, she would quickly die. She immediately agreed to the surgery.
A transverse C-section incision was made. Immediately, a tiny umbilical cord appeared, floating in the blood-filled abdomen. The fetal head was then seen protruding from a macerated uterine fundus with the placenta attached in the right uterine cornu. (This was a "cornual pregnancy," gestation in the horn of the uterus).
The now dead fetus and remaining placental tissue were quickly removed from the uterus through the gaping fundus. The fundus was then clamped and oversewn. At that point, the patient was hypotensive (80/40 mmHg) and receiving both packed erythrocytes and crystalloid. About 4L of sanguineous fluid was removed from her abdomen. After ascertaining that bleeding had ceased, the fallopian tube that had not been removed with the uterine fundus was ligated and bisected.
Following surgery, the patient's condition improved with fluids and blood administration. The next day she was stable, with normal vital signs, a postoperative ileus, and pain only at the incision site. She was discharged two days later.