Clinical History:

A 23 year-old woman, who had not had a menstrual period for seven weeks, began to experience vaginal bleeding and right lower quadrant pain. The urine HCG level was elevated. A small amount of tan tissue was passed per vagina. An incomplete abortion was suspected clinically.

Image 7.1:

At laparotomy the right fallopian tube was dilated and ruptured with surrounding hemorrhage. A right salpingectomy was performed and the specimen is shown here.

Image 7.2:

A histologic section of tissue removed at D&C showed only decidua and gestational endometrium, and no fetal tissue, chorionic villi, or trophoblastic cells were seen. The abdominal pain persisted. This image demonstrates what was seen in the tube. The right fallopian tube is distended by extensive hemorrhage. Occasional tubal mucosal fronds are present at the periphery (upper left) of the lumen.

Image 7.3:

There are immature (double layered) chorionic villi within the intraluminal blood.

Answers:

1. What is the diagnosis?

Tubal ectopic pregnancy. The fallopian tube is the most common site of an ectopic pregnancy. Less common sites include ovary, abdominal peritoneum, and the intramural (uterine cornual) portion of the tube. Rupture of the tube may cause extensive life-threatening, intraabdominal hemorrhage.

2. What is a risk factor for this condition?

Prior salpingitis with tubal inflammation and scarring can increase the risk for ectopic pregnancy. The two most common infections are Neisseria gonorrhoeae and Chlamydia trachomatis. Previous surgery, or other causes for chronic salpingitis, can also increase the risk. However, half the time, no risk factor is identified.


3. What issues are raised when the patient is a minor? Is parental consent required?

The concepts of emancipated minor and mature minor need to be addressed.

An emancipated minor is one who has escaped or been freed from childhood. This concept pictures childhood as an unpleasant condition and usually applies to children for whom childhood WAS an unpleasant condition: overly controlling parents, or worse--abusive. The criteria to be emancipated: married, or in the military, or living apart from the parents and self-supporting.

The mature minor status is an achievement rather than an escape; it means the child has decision making capacity. It is up to the clinical judgment of a physician to determine this. If the child understands her condition, her options, and the consequences of her choice, then just document in the chart that she is a mature minor and thus you have let her make the decision.