Early pregnancy: Size of uterus four(ish) weeks after implantation

Los Pollos Hermanos · Jan 19, 2014

Hello! I was wondering if any of you good people with medical knowledge may pretty please be able to help here?

A female character needs emergency abdominal surgery after a stabbing (two deep wounds around waist level). Whilst the laparotomy is underway, the surgeon notices her uterus is slightly enlarged, suggesting an early stage of pregnancy.

For the timeline to work, I need her to be about six weeks pregnant, so four weeks after the fertilised ovum has implanted. Neither she nor her husband know she's pregnant, the briefly mentioned backstory will be that she's always had irregular periods. This is not a planned baby, and she has had no obvious signs of early pregnancy. Anything like feeling tired and weepy would be masked by the events which lead up to the stabbing.

My hour of googling last night revealed that apparently changes can be noticed in the uterus as early as two weeks after implantation and, by eight weeks, the uterus has increased from the size of a pear to the size of a grapefruit. I cannot find anything for between these stages though!

So, here comes question time, assuming she's four weeks post-implantation:
1). Would a surgeon be able to detect changes in size (or colour or anything else) in the uterus this early?
2). If so, what would they see?
3). If not, would changes be evident/more obvious at this stage if she was carrying twins instead?
4). Is there a quick test the surgical team could do during surgery if they needed to confirm a pregnancy? Ultrasound? Blood test? Urine?
5). Anything else which may be useful?

It's not a massive scene in itself, but subsequent events have BIG ramifications so I need it to be as accurate as possible.

Many thanks in anticipation,

LPH.

ULTRAGOTHA · Jan 19, 2014

Here is a web site I found googling "development of fetus"
http://www.babycenter.com/fetal-development-week-by-week

Los Pollos Hermanos · Jan 19, 2014

Many thanks - it's a clear and concise website. The problem is that I know the uterus won't be much bigger than its unpregnant state so early in pregnancy.

I've read about the vulval, vaginal and cervical tissues taking on a blue-ish tinge due to the increased blood supply in the pelvic region, but cannot find anything about whether or not this also applies to the uterus (I suppose because you can't have a look at your uterus!!). The woman won't look pregnant and won't be able to feel the top of the uterus if she presses above her pubic bone at this stage.

Hence I wondered if a surgeon would notice uterine changes during the laparotomy? She's taken straight to the operating theatre/OR (haemodynamically unstable) and opened up. Sadly, she will miscarry soon after the (successful) surgery, but I don't want the surgical team to not notice her pregnancy and assume she's begun a normal period. However, a few years ago a close friend had a miscarriage at this early stage, and she said the experience was nothing like a normal period (in terms of blood volume, clots, pain, etc.).

My character will be in a high dependency/step-down unit after surgery and, due to a combination of painkillers and sedatives, will have no idea that she miscarried a pregnancy she wasn't aware of.

Her husband will be told by the surgeon as part of the post-surgery update (his wife will eventually find out when her condition improves). To say he'll be angry is somewhat of an understatement...

Thanks,

LPH.

afarnam · Jan 19, 2014

I had a miscarriage at about that stage once and you are right. It wasn't like a normal period. Actually a bit frightening. It does depend and sometimes it probably isn't that bad but in my case it was.

That said, I know all the facts you are talking about with size but I don't know enough about medicine to know if a surgeon could tell. You could definitely tell from a blood test though and might there not be a blood test of some sort involved in the surgery? Even though they aren't testing for pregnancy, I've heard many stories about someone being tested for something completely different and the report comes back and "Hey, by the way, you're also pregnant."

BrightSera · Jan 19, 2014

They would absolutely do a pregnancy test before surgery on a woman of childbearing age. It's a quick urine test or blood test, there's no reason not to.

Los Pollos Hermanos · Jan 19, 2014

Afarnam: Thanks for the reply and I'm sorry to hear about your miscarriage.

The only pregnancy test I'm familiar with are the "pee on a stick" type. I know blood tests show pregnancy (not sure of details, but google will sort that out!). My idea is that the surgeon notices changes in the uterus and does some sort of pregnancy test.

I know my Aunt had her appendix out over 40 years ago and the doctor asked her afterwards if she'd known she was pregnant. She didn't know, and I don't know how advanced the pregnancy was at the time apart from that it was "early", but I do know that she miscarried soon after (this is what triggered my idea). However, I can't ask her as we're not that close and I wouldn't want to potentially upset her.

BrightSera: When she arrives at hospital she's lost a lot of blood, is in a very unstable condition and they get her straight in for surgery. According to a number of medical/trauma websites I use this would be the protocol.

She was found barely conscious and loses consciousness en route in the ambulance. Current research says they'd use O- blood until cross-matching could take place, but whether that information would come through during surgery so they could give her her actual blood group, I have no idea. Do you know how long it takes to do a blood test for pregnancy, and whether one would be carried out at the same time as the cross-matching?

Thanks to you both for your replies,

LPH.

melindamusil · Jan 19, 2014

Not a medical professional, but...
I'm pretty certain that if a woman of childbearing age comes into the hospital, and if any procedures need to be done, the doctors will basically always do a pregnancy test. Of course, they will ask the patient if possible, but since patients are not always honest about their sexual past, they can't always be trusted. Certain medicines and a aesthetics will affect a pregnant woman differently than a not-pregnant woman. Plus if the patient needs an X-ray or CT scan, the X-rays can be bad for a fetus.

Also, especially in the US, there's always the concern about malpractice. You don't want to be sued because you gave the woman too much anasthetic and she miscarries.

When I was in my car accident, I was taken to the ER unconscious, and I'm pretty sure a pregnancy test was one of the the many tests they ran, along with stuff like my blood alcohol levels, oxygen levels in the blood, that kind of thing.

afarnam · Jan 19, 2014

They would do the test as soon as they could but there are trauma cases where a person is taken right to some sort of surgery. I think the key question is the one you mention about whether they would discover the pregnancy during cross-matching and therefore whether you can play the card of the surgeon being surprised by the changes to the uterus. I don't know that myself but at least you have a very specific question when you do find a medical person.

Old Hack · Jan 19, 2014

If she was given surgery for "two deep wounds around waist level" then I doubt that the surgeons would see her uterus: it's very low in the pelvis, even in early pregnancy, and it's hidden behind the bladder, I think. Nowhere near the waist. So you probably are better off relying on a pregnancy test rather than a visual diagnosis.

Los Pollos Hermanos · Jan 20, 2014

Thanks for the additional replies.

So, if one of the stab wounds in the story was lower down, is it more likely the surgeon would see her uterus? I'm thinking about my Aunt's experience with the apendectomy (which I've only heard about via my Mum) - the incision would have been lower and therefore more likely to allow the surgeon sight of the uterus. I assume?!

If the medical team (also) go for the pregnancy test option, when would they carry out the test? Bearing in mind she's been wheeled pretty much straight into surgery and is unconscious through severe blood loss.

A new idea is to make her blood loss less severe than first planned. This gives the trauma team enough time to carry out a FAST scan - could this detect a singleton/twin pregnancy only four weeks after implantation?

Thanks again,

LPH.

melindamusil · Jan 20, 2014

Los Pollos Hermanos said:
So, if one of the stab wounds in the story was lower down, is it more likely the surgeon would see her uterus? I'm thinking about my Aunt's experience with the apendectomy (which I've only heard about via my Mum) - the incision would have been lower and therefore more likely to allow the surgeon sight of the uterus. I assume?!

Do you know for sure that your aunt's pregnancy was diagnosed by visual inspection? Even if they run a (blood/urine) pregnancy test beforehand, and even if it's positive, telling the family about the pregnancy may not be at the top of a surgeon's list in a trauma situation. (thus they would tell the family later, after the patient is stabilized, along with all the other info about the patient's condition.) It would be different if it was a scheduled procedure. Do you know if your aunt's appendectomy was an emergency or a routine procedure?

Also, remember that your aunt's surgery was 40 years ago. My dad, who had his appendix out 50 years ago, has a good 4-5 inch scar. The doctor would open the abdomen and would see quite a bit. However, nowadays it wouldn't be uncommon for a patient to have a laproscopic appendectomy, with a much more focused point of view.

(Of course, your character is in a trauma situation, which could somewhat negate that point; of course doctors won't cut you open any more than necessary, but in a trauma situation they are not afraid to open you up as much as necessary.)

Koelsong · Jan 20, 2014

Scans happen about 20 weeks. Before that it's just a little blob. And unless the doctor was actually looking for it, it's doubtful he will just notice it.

Four weeks after implantation is 6 weeks pregnant. It would be a dot on the screen. I'm also sure that, unless the wound went through the uterus, the surgeon wouldn't take a bit of notice of it. There are a LOT of organs around there. She would be more concerned about getting the camera in the right place than looking at the uterus for pregnancy. the abdomen is not a great, vast space. It's squishy and looks nothing like the pictures of organs in anatomy books.

You can detect pregnancy with a blood test at 4 weeks. Stick to that and leave off the overcomplication, or those of us with a physiology background will be going 'wtf' when we read the story...

M

Old Hack · Jan 20, 2014

This is probably going to be too much information for some, but it might be helpful.

I have a picture of a scan of my eldest son (now 18 and over six feet tall!) which was taken at five weeks pregnant--so three weeks' gestation. He looks like a little kidney-bean, and I think there's a note that he was just 5mm long at that time.

When I was eleven weeks' pregnant (nine weeks gestation) with my youngest (now thirteen) I had transabdominal cervical cerclage to ensure I didn't miscarry. I had an incision like a caesarian, which was about six inches wide, I think; one senior surgeon lifted my uterus very slightly out of my abdominal cavity and held it while another fixed a suture around the outside of my cervix.

After the surgery the surgeon who held my uterus out of the way told me that he could feel my baby moving around throughout the whole procedure.

I've always thought that was amazing.

As for whether a surgeon would see the uterus if the stab wound was further down: I'm no expert in anatomy but as far as I know, the bladder sits right in front of the uterus, and the uterus itself sits very low, right down in the pelvis. My betting is that it's all going to be far too tucked away and hidden by other structures for your surgeon to notice that there's a pregnancy going on, especially when your character is so early on in pregnancy. If I were you I'd stick with the routine pregnancy testing idea: it's so much easier.

Los Pollos Hermanos · Jan 20, 2014

You people are great!
Thanks so much for taking the time to help.

I know my Aunt's pregnancy was picked up during her appendectomy, and that she lost the baby soon after (the next two pregnancies were successful, btw). Not sure how urgent the surgery was, although Mum said my Aunt didn't know she was pregnant beforehand.

Another option for my storyline is to return to the unconscious due to severe blood loss requiring emergency surgery scenario, and she miscarries either during or immediately after surgery. However, wouldn't that leave the hospital open to potential accusations of negligence for not doing a pre-surgery pregnancy test? (That wouldn't happen with this family, but the powers that be wouldn't know that).

This is from a UK NHS document:
In emergency situations, confirmation of pregnancy should not delay treatment and should be judged within clinical assessment of risk.
I assume the same applies in other countries? Would doing a pregnancy test as an addition to the cross-matching, etc whilst she's in surgery be commonplace, and then the surgeon be informed?

Hmmm...

Thanks again!

LPH.

Los Pollos Hermanos · Jan 20, 2014

Old Hack - That's fascinating! Thanks for sharing.

I'm quite happy to go for the pregnancy test option, but the only specific online information I can find about emergency surgery is when the woman is still able to answer questions and give consent for a pregnancy test. My character is unable to do either!

I know the surgery would take 60-90 minutes, assuming there's no complications - would the test results come through during surgery if blood was taken for cross matching, etc near the start?

I think that makes vague sense?!

Thanks...

LPH.

melindamusil · Jan 20, 2014

Old Hack said:
As for whether a surgeon would see the uterus if the stab wound was further down: I'm no expert in anatomy but as far as I know, the bladder sits right in front of the uterus, and the uterus itself sits very low, right down in the pelvis. My betting is that it's all going to be far too tucked away and hidden by other structures for your surgeon to notice that there's a pregnancy going on, especially when your character is so early on in pregnancy. If I were you I'd stick with the routine pregnancy testing idea: it's so much easier.

Plus you have to remember that surgeons tend to have laser-focus on whatever organ they are treating - not scouting around the abdomen for the fun of it.

Los Pollos Hermanos said:
Y
This is from a UK NHS document:
In emergency situations, confirmation of pregnancy should not delay treatment and should be judged within clinical assessment of risk.
I assume the same applies in other countries? Would doing a pregnancy test as an addition to the cross-matching, etc whilst she's in surgery be commonplace, and then the surgeon be informed?

I think it's almost standard in medicine worldwide to do the best you can with what you've got - especially in emergency medicine. That is to say, in a NON emergency situation, the patient will answer lots of questions and fill out lots of forms, and it would be considered irresponsible for the doctor to not ask about the patient's medicinal history and any conditions that might affect the procedure. However, if you've got an emergency patient who is in serious/critical condition and unable to give their medical history, the odds change, and it's better for the physician to treat as best they are able.

ETA: my point was, under ordinary circumstances, it might be irresponsible for a doctor to knowingly give a pregnant patient a medicine known to cause miscarriage or birth defects. But under trauma/emergency situations, it's different - when it comes down to "lose a possible pregnancy but patient will live" or "let both mom and baby die", they usually go with the former.

Orianna2000 · Jan 20, 2014

When I had an appendectomy back in the 1980s, the surgeon took a peek at my ovaries and informed me afterwards that I was within a year or two of starting my first period (I was ten at the time). My scar is about two, maybe three inches long. I don't know how easy it is to find the uterus compared to the ovaries, though. And my surgery was not emergency, it was scheduled after I had severe abdominal pain and vomiting. Turns out I had salmonella, but the test results didn't come back fast enough and they were worried my appendix would rupture if it was appendicitis, so they went ahead and removed it.

Old Hack · Jan 20, 2014

The appendix is very low down, though, isn't it? I was told once that if you put your right thumb in your belly-button and your little finger on your hip-bone, with your fingers pointing down, your middle finger will lie roughly above your appendix.

A friend of mine had to have her appendix out when she was eight months pregnant: because the baby-filled uterus displaces all the internal organs, her appendectomy scar is up near her rib-cage now.

Marian Perera · Jan 21, 2014

Los Pollos Hermanos said:
The only pregnancy test I'm familiar with are the "pee on a stick" type. I know blood tests show pregnancy (not sure of details, but google will sort that out!).

The blood test also checks levels of beta-HCG (human chorionic gonadotropin), except it's much more precise. The urine test is qualitative, the blood test is quantitative, so it can give an indication of how advanced the pregnancy is. If there's a chance of a miscarriage, beta-HCG levels would be tested. Maybe fetal fibronectin as well? Not sure about that one.

She was found barely conscious and loses consciousness en route in the ambulance. Current research says they'd use O- blood until cross-matching could take place, but whether that information would come through during surgery so they could give her her actual blood group, I have no idea. Do you know how long it takes to do a blood test for pregnancy, and whether one would be carried out at the same time as the cross-matching?

Yes. O negative blood is always given to women of childbearing age who need a transfusion if there's no time to do tests. And yes, in the hospital where I worked, there'd be three tubes taken - one for hematology (check blood counts and platelets), one for chemistry (check beta-HCG level) and one for transfusion, so all could be done simultaneously.

The beta-HCG test took a little time, maybe twenty or thirty minutes. What we'd do, in an emergency, would be issue however many O neg units the surgeon wanted, but they wouldn't take all of those at once. So while those units were sitting labelled in the fridge and ready to go, we'd be typing and crossmatching the patient's sample so we didn't waste all our O neg units on someone who'd be fine with A pos.

Los Pollos Hermanos · Jan 21, 2014

Once again, I am overwhelmed by the amount of help/advice/suggestions. I also enjoyed (not sure that's the correct word, but hey-ho) the medical curiosities - I love stuff like that. Many thanks!

Soooooo... current plan for what will get written in the next week or so. Character gets admitted to hospital as a dire emergency after suffering the two stab wounds and losing a lot of blood (I'm secure on the medical aspects of this). She's unconscious and rushed straight into surgery. O- blood is ordered and the three blood samples are taken away for assorted testing. 30 minutes later her actual blood group is determined, as is a positive beta HCG test.

Quick question 1: How would the surgical team learn this information? Would someone visit them in person or would it be phoned through?

Immediately after surgery she will begin to miscarry. The rest of the storyline is all planned from this point.

Quick question 2: Who will tell her husband about the surgery and miscarriage? Surgeon? Doctor on duty in the high dependency/step down unit? Nurse?

Big thanks!

LPH.

Marian Perera · Jan 21, 2014

Los Pollos Hermanos said:
Quick question 1: How would the surgical team learn this information? Would someone visit them in person or would it be phoned through?

In the hospital where I worked, the info would be phoned through. Most labs are just too busy to deliver even stat results in person, and you don't need people going into the OR unless it's absolutely necessary. The one time I had to go there to take blood from a patient who was actually in the middle of emergency surgery, I had to get all suited up and that took time.

Los Pollos Hermanos · Jan 21, 2014

Many thanks - you've just achieved "legend" status!

Tazlima · Jan 21, 2014

The scars for uterine surgery on a non-pregnant woman are right along the top of the pubic hair hairline (or is it pubic hairline)?

Anyway, that should give you a pretty good idea how low the stab wound would have to hit.

Plains Pen · Jan 21, 2014

Quick question 1: How would the surgical team learn this information? Would someone visit them in person or would it be phoned through? In a lot of US hospitals now, the results will come up on the computer, where the staff can review them. This wouldn't be addressed in the middle of surgery likely, but as she is going to the recovery room or a bed on the post-op floor, the nurses and providers would find it.
Immediately after surgery she will begin to miscarry. The rest of the storyline is all planned from this point.If she begins with bleeding and cramping right after surgery, be aware that the surgeons may start getting worried about another injury to the uterus which might have been missed at the time of surgery, and then they would do a transvaginal sonogram to try to sort out whether or not it was miscarriage or a laceration from the stab wound. This would be an emergency procedure because if she is really bleeding from a traumatic cause, they would want to take her back to surgery right away.

Quick question 2: Who will tell her husband about the surgery and miscarriage? Surgeon? Doctor on duty in the high dependency/step down unit? Nurse?
Likely a positive pregnancy test would be shared with her by one of the physicians -- or a medical student/resident if it is at a teaching hospital or a physician assistant at some community hospitals. Most frequently the main surgeon will have a discussion with family members after the procedure, but I doubt he would know of the positive pregnancy test then. Perhaps the next morning on rounds he would share the news. Sometimes nurses will share this information with patients, but then some doctors get testy about that, so that would be less common I think. Perhaps if the nurse knew the doctor would be OK with it, he or she might be the first one to mention the pregnancy part.
Big thanks!

Los Pollos Hermanos · Jan 21, 2014

Questions, questions... so many questions!

1). Would the results of the blood cross matching phoned/internally emailed through during surgery not also have (in screaming red letters?!) PREGNANT along with them? Or, would that be revealed afterwards?

Therefore, if the surgeon knew, he'd be able to share the info with her husband - who will be frantic with worry because the last thing he heard was that his wife was in recovery and now there's been a long delay.

2). How long would it take for her to miscarry and the resulting medical investigations/treatment to occur?

She won't be told about the miscarriage for a day or two, until her condition has sufficiently improved.

Huge thanks!

LPH.

Early pregnancy: Size of uterus four(ish) weeks after implantation

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