This case report describes a novel diagnostic approach for ectopic pregnancy in a combat environment. We diagnosed a ruptured ectopic pregnancy at our combat support hospital by using the SonoSite 180 Plus ultrasound device (SonoSite, Bothell, WA). The live ectopic pregnancy was immediately identified and the entire pelvic anatomy was easily assessed within 5 minutes. The SonoSite ultrasound device proved to be easy to use, durable, and reliable. It produced high-quality images in a variety of applications. The handheld SonoSite 180 ultrasound device is sufficiently portable to be used effectively in a combat support hospital or field situation, such as a forward surgical team. This combat experience suggests that a handheld ultrasound device may also have great utility during patient transport for civilian hospitals.
Introduction
This case report describes a novel diagnostic instrument and a unique environment for a common obstetric complication, namely, ectopic pregnancy. The surgical case described occurred in a combat support hospital (CSH) during Operation Iraqi Freedom. To our knowledge, this is the first reported ectopic pregnancy to be diagnosed with a field-ready, handheld, portable ultrasound device and definitively treated in a CSH. We diagnosed the ectopic pregnancy with a handheld SonoSite 180 Plus ultrasound machine (SonoSite, Bothell, WA), which provided high-quality observation of the pathologic condition. We describe clinical techniques adapted for the combat environment and critique the portable handheld ultrasound machine as a field device for combat.
Case Report
The patient, a 27-year-old, gravida 2, para 1-0-0-1 active duty woman in the U.S. Army was transported to the 21st CSH emergency department for evacuation from the Operation Iraqi Freedom combat zone for a first-trimester pregnancy, according to theater policy. The patient had been deployed to the Central Command area of operation 7 to 8 weeks before presenting to the 21st CSH. Upon presentation to the 21st CSH, the patient complained of nausea, vomiting, diarrhea, pelvic pain, and bloating for 2 weeks, without vaginal bleeding, anorexia, or fever. The pelvic pain had increased acutely 2 days before presentation, at which point physicians at a remote clinic diagnosed the patient with a pregnancy via a urine human chorionic gonadotropin assay. They also diagnosed a urinary tract infection via urinalysis. The patient's last normal menses had been 7 to 8 weeks earlier, in early March 2003, but she had experienced brief vaginal bleeding 4 weeks earlier, on April 13 to 14, 2003. Her first pregnancy was uncomplicated and resulted in normal spontaneous vaginal delivery of a healthy term neonate. The patient was heterozygous for factor V Leiden. She had no history of thrombophilia-related, adverse obstetric outcomes or medical complications. She had experienced a single episode of genital herpes simplex virus outbreak; her medical history was otherwise unremarkable. She had undergone eye surgery as a child, without complications. She had no known allergies. She did not use tobacco or illegal drugs. She was taking oral doxycycline for malaria prophylaxis and an unknown oral contraceptive. The physical examination revealed benign results, except for mild abdominal and adnexal tenderness without guarding, rebound tenderness, or cervical motion tenderness. The uterus was approximately 6-week size, with a palpable 5-cm left adnexal mass. On the basis of these clinical findings, the emergency medicine physician consulted the gynecologist. A transvaginal ultrasound examination (SonoSite 180 Plus; SonoSite) in the emergency room revealed a large amount of fluid in the posterior cul de sac, an empty uterus, a 4-cm simple right ovarian cyst, and a gestational sac that appeared to be in the distal left fallopian tube or ovary. A fetal pole with cardiac activity and a yolk sac were noted. The crown-rump length (10.9 mm) was consistent with a gestational age of 7 weeks 1 day (Figs. 1 and 2). The patient was counseled regarding the risks of ectopic pregnancy and the risks and benefits of surgery. After informed consent was obtained, the patient was immediately taken to the operating room for an exploratory laparotomy through a Pfannenstiel incision. Upon entry into the peritoneum, a large amount of blood (500 ml) was noted and evacuated from the abdomen and pelvis. After establishment of good observation of the pelvic anatomy, a left distal ampullary pregnancy was identified. The pregnancy had ruptured the fallopian tube and was in the process of aborting into the abdomen. The pregnancy was manually removed from the tube and hemostasis was achieved, with eare not to distort the tube or fimbria further. A salpingectomy was not performed because the tubal damage was isolated to a small portion of the distal ampulla. In an examination of the products of conception, a small fetus and an intact gestational sac were observed. Because the surgery was performed in a CSH, the patient received intravenous cefazolin intraoperatively and postoperatively. Her hematocrit decreased from 38.3% preoperatively to 29.1% postoperatively. The patient had an uncomplicated postoperative course and was evacuated to the United States on postoperative day 3 for additional convalescence.
Discussion
Ectopic pregnancy is the implantation and development of a pregnancy external to the endometrial cavity and can occur in the fallopian tube (97.7%), abdomen (1.4%), ovary (
As the U.S. Army deploys an increasing number of female soldiers, there is clearly a need for emergency and acute gynecologic care in combat zones to maintain a healthy fighting force. During Operation Iraqi Freedom, 15% of active duty Army soldiers were female, which translates to approximately 45,000 women of reproductive age being deployed to Southwest Asia. Because ectopic and intrauterine pregnancies are relatively prevalent, the occurrence of these events could significantly hinder the ability of the U.S. Army to accomplish its mission. On the basis of population risk estimates, the predicted numbers of ectopic pregnancies and maternal deaths for Operation Iraqi Freedom soldiers in a brief window of time are 68 and 1, respectively. Therefore, it is necessary for the Army to use a rapid, field-ready algorithm for the diagnosis and treatment of ectopic pregnancy.
At the CSH, we used the SonoSite 180 Plus to diagnose an ectopic pregnancy (Fig. 1). The live ectopic pregnancy was immediately identified, and the entire pelvic anatomy was easily assessed within 5 minutes. We also used the ultrasound machine for abdominal, pelvic, and renal sonography and for the focused assessment with sonography for trauma (FAST) examination for abdominal trauma patients. The SonoSite was also useful in the bedside diagnosis of renal lithiasis, cholelithiasis, intra-abdominal hemorrhage from a shrapnel-induced liver laceration, retinal detachment, ovarian cysts, and tubo-ovarian abscess.
The SonoSite ultrasound device proved to be easy to use, durable, and reliable. General surgeons, emergency medicine physicians, and gynecologists were proficient with the machine after minimal training (30 minutes). The SonoSite withstood severe desert conditions, including heat, wind, and sand. Enclosing the device in a plastic bag and leaving a transducer in the rear port likely helped avoid damage in the desert environment.
The SonoSite produced high-quality images in a variety of applications. The transvaginal transducer seemed, subjectively, to provide better-quality images than the transabdominal transducers, but all abdominal images were adequate for clinical use. Similarly, Théodore et al.2 reported that the SonoSite transabdominal transducers produced images of lower resolution and lower quality than did a larger, portable, ultrasound machine (General Electric Logiq 400; GE Healthcare, Milwaukee, Wisconsin). However, the clinical details of the images were similar for the two machines.2 Pieckenpack et al.3 reported that the handheld SonoSite machine produced satisfactory results but that at times the clinicians experienced uncertainties because of the small viewing screen. We share their concerns about the small screen but think that it did not adversely affect diagnostic capability or clinical outcome.
