Ruptured Ectopic Pregnancy with Shock with Severe Anemia in Rural Nepal, Managed By GP

Dr. Bikash Gauchan

This is a real story from the rural The Far Western Region of Nepal in Achham District which is often considered the remotest and poorest region in whole South Asia.

20 years old female presented with Abdominal Pain for the last 7 days at Bayalpata Hospital in Achham District of Nepal. The Clinical Team of Bayalpata Hospital is lead by General Practitioner. The female described her abdominal pain to be diffuse, constant, and severe. She also developed multiple episodes of vomiting. She just married two months ago and she was having regular menstruation cycles two months ago after which she started to have irregular flow and the amount of flow was reduced. When I evaluated her she was in severe pain. Her abdomen was severely tender. She was pale. We performed ultrasound and found there is fluid collection intra-abdominally suggestive of blood and her urine for pregnancy test came to be positive. We finally came to the conclusion that she had Ruptured Ectopic Pregnancy. The next level of hospital from Bayalpata Hospital is 10 hours jeep ride and the lady did not have that many hours is she was referred to higher center.

There was dilemma what to do and what not to do. Dr. Santosh Kumar Dhungana and I decided to proceed for Exploratory Laparotomy at our own facility, Bayalpaya Hospital. We arranged blood donors for her as she is O positive. Luckily we were able to find some donors from our own staffs and from the armed police force. People in this part of hilly region do not want to give blood and our blood bank lacks necessary blood all the time and we always have hard time explaining people why blood donation is important to save lives.

Dr. Santosh gave general anesthesia and worked very closely with one of our staff nurses. Another staff nurse scrubbed with me. I proceeded with the surgery. When I opened the peritoneum, gush of blood came out of her abdomen and nearly 40 % of scrub nurse and my body were wet by the blood. We calculated the intra – abdominal collection to be more than 2 litre. We drained all the blood. The ectopic pregnancy was located on the right fallopian tube at Ampulla and there was small site of perforation from where blood was continuously oozing. We performed right tubectomy. And inserted Right Abdominal Drain. We started blood transfusion for her. After 2 hours of surgery and one hour of close monitoring she was transferred to ward to close monitoring.

One the 4th Post operative day, we were able to remove her abdominal drain and she was discharged home on 8th day of operation. Bayalapata Hospital has two GPs and they feel very proud to save this lady.

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Dr. Bikash Gauchan  MBBS, MD  Medical Director Bayalpata Hospital - Nepal