A 26yo woman presented at 36 weeks gestation in her third pregnancy with headache, nausea, blackouts in association with pain in the left side of her lower abdomen. She had pushed for over two hours in the second stage of her first labour which had been “prolonged” and “difficult”. Physical examination revealed slight tenderness on the left side of the abdomen. Her symptoms did not occur if she was lying on her right side I.e. left side upwards. All investigations were negative.
POSSIBLE INTERPRETATION. These are typical, non-specific symptoms associated with activation of the autonomic nervous system. In this case the weight of the pregnant uterus pressing on the scar tissue in her pelvis from her previous pregnancy may cause the symptoms. Difficult to prove but there will be MRI soft tissue abnormalities from the previous delivery, and, abnormalities at laparoscopy.
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Some clinical guidelines rely on “hierarchies” of evidence. These documents rely on assembling “evidence” according to the manner in which it has been gathered ! The error is obvious, and, elegantly articulated by Professor Sir Michael Rawlins in his Harveian oration in 2008. (Such “hierarchies” are “illusory”, and, do not appear in legal textbooks).
“Evidence” is “information tending to establish a fact”. “Facts” are reliable, often verifiable, pieces of. information. “Judgment” establishes facts and applies them in the relevant context.
“Hierarchies” of evidence are therefore illusory constructs where their authors hide behind imaginary taxonomies to avoid deploying the critical faculty of “judgment”. It is remarkable that some arrays of clinical guidelines harbour these defects in their construction and analysis.
Regrettably, they may affect some descriptions of chronic pelvic pain, and, endometriosis.
A 36 yo woman with a past history of two surgeries for termination of pregnancy, underwent IVF with replacement of two embryos. Twenty three (23) days after embryo replacement she presented with right sided pain. Investigations including laparoscopy, demonstrated a ruptured ectopic pregnancy that required laparoscopic removal (salpingectomy). The left tube appeared entirely normal. Her B-HCG hormone levels did not return to normal, they started to go up again. Forty five (45) days after embryo replacement she presented with left sided pain and required removal of the second Fallopian tube.
Examination under the microscope using special stains, showed that the right Fallopian tube showed large numbers of abnormal nerves whereas there were NO nerves in the left tube. The patient subsequently returned for further IVF.
POSSIBLE INTERPRETATION This is a particularly rare and unusual presentation of ectopic pregnancy – you could call it “bilateral asynchronous ectopic pregnancy”. Having two ectopic pregnancies in two tubes at the same time (synchronous) is also rare – but more common than the asynchronous form.
Prior injuries to the respective Fallopian tubes may have resulted from prior termination of pregnancy. Excessive, abnormal nerves may result from excess uterine curettage, complete absence of nerves in the Fallopian tube may result from excessive traction on the cervix that leads to avulsion of the left uterosacral ligament and nerves to the left side of the uterus and Fallopian tube.
A 26 yo woman presented with right-sided pelvic pain at eight weeks gestation. Her pregnancy test was positive and a vaginal ultrasound scan showed an empty uterus with a mass on the right side of the uterus. A laparoscopy was performed. A right-sided, ectopic pregnancy was identified. The tube was surgically removed (salpingectomy). She was warned of the risk of another ectopic pregnancy in a subsequent pregnancy.
The above is a typical account of the diagnosis and clinical management of the life-threatening condition of ectopic pregnancy. Women still die in the UK from the consequences of undiagnosed rupture of the tube with severe intra-abdominal bleeding. Mortality rates are much higher in developing countries.
There are some additional facts to this woman’s story. First, she had a previous history of three surgical terminations of pregnancy (TOP). Second, at the laparoscopic examination she had injuries to the ligaments and nerve supply of her uterus and Fallopian tube. Third, when they looked at the removed Fallopian tube under the microscope with special stains, she had markedly abnormal patterns of nerves in the cross section of the Fallopian tube. The same findings have been made in over 100 cases of ectopic pregnancy. The changes were independent of infection, and, other associations with ectopic pregnancy.
POSSIBLE INTERPRETATION Injuries to the nerve supply of the uterus and Fallopian tube are caused by excessive curettage or over-vigorous traction on the cervix when a woman is under anaesthesia. Injured Fallopian tubes do not function correctly. The pregnancy implants in the Fallopian tube – instead of the uterus – where it forms an ectopic pregnancy.
A 32 yo woman with two children aged 5 & 3 years presented with pain in the 24 hours before the onset of her period. The pain was severe and not relieved by anything other than the start of her period. Her first pregnancy had been complicated by a difficult vaginal delivery.
Clinical examination revealed specific tenderness associated with lifting the cervix. There was bilateral tenderness on both sides of the uterus.
Laparoscopy showed there was a clear localised injury at the junction of the uterus and vagina. The right uterosacral ligament, cervix and lower uterus all appeared to be involved. A Mirena IUS was inserted with considerable improvement of her symptoms.
POSSIBLE INTERPRETATION: It is possible that this patient had a significant injury during her first labour affecting her cervix, lower uterus and uterosacral ligaments. Muscles, nerves and ligaments were injured as demonstrated at laparoscopy. Nerves were clearly injured because of the injury to the uterosacral ligament – that contains some of the nerve supply to the uterus and Fallopian tube. Subsequent regrowth of nerves caused pain 4-5 years later just before the onset of her period i.e. associated with increasing pelvic blood flow. Putting a Mirena in the uterus reduced her symptoms significantly since it reduces pelvic blood flow. We interpret this injury as a localised injury that was likely respond to the Mirena IUS.
A 26yo woman presented at 20 weeks in her second pregnancy with symptoms of faints, nausea and vomiting at different times of day. She also had some tenderness in the lower right side of her abdomen. She had a difficult first labour which was prolonged, complicated by prolonged pushing (> 2 hours) and resulted in delivery of a baby weighing 4200g. The child was now 5 years of age.
We performed two ultrasound examinations. On both occasions we found that her symptoms were clearly associated with pronounced fetal movements. The baby appeared to be kicking vigorously on the right lower side of her uterus and this reproduced her symptoms.
INTERPRETATION: We interpret these findings as showing that this patient may have an injury to the right side of her uterus with scarring and re-growth of abnormal nerve profiles (see Home Page for typical appearances). Kicking by the baby cause some stimulation of her injured uterine nerves resulting in these non-specific autonomic symptoms. The mother understood her situation, realised that she may have to lie down during pronounced fetal activity, and, avoided taking any tablets.
Importantly she understood what had happened to her and why she was experiencing these symptoms.
The September edition of Fertility & Sterility – one of the important journals in Reproductive Medicine – carries a series of articles on endometriosis. One, in particular, by Professor Jacques Donnez asserts that endometriosis is STILL an enigma, that we do not understand it, etc. Our group has submitted a reply.
Gynaecological surgeons can continue to burn or ablate, individual spots of endometriosis in long, complex operations that cost a great deal of money (and do not help the woman) while guidelines remain as they are. Women will do better if they find out everything they can about their condition. Particular questions that may be helpful :
(1) when will my symptoms improve ? (Answer: immediately)
(2) will you get rid of all my pain ? (Answer: NO)
(3) how long can I expect to be pain-free after the operation ? (Answer: 50% recur in five years)
A 25 yo woman presented with three years of subfertility. She had no previous pregnancies or surgical operations. She did not suffer from constipation. She was taking no medication.
Laparoscopy showed the appearances on the left. The pelvis was largely normal with free fill and spill of dye through the Fallopian tubes. The image shows an injury half way along the right uterosacral ligament with brown spots of endometriosis at the site of the injury. It is an unusual site to find an injury to the uterosacral ligament.
In the discussion after the operation with the patient, she confirmed that she suffered a serious fall from a tree at the age of 7 years. She did not break any bones but she suffered extensive bruising around her pelvis. She was in bed for a week and suffered pain for several weeks afterwards. Her periods started at the age of 11 years.
This is an unusual appearance of “endometriosis” with an unusual injury to the uterosacral ligament. It follows the sequence of injury to ligament-injury to contained nerves-retrograde menstruation -adhesion of endometrium to the prior pelvic injury. The patient is due to receive IVF.
(Patient details have been adjusted to protect the identity of the patient. The patient gave consent for this case report)