What's the Diagnosis? By Dr. Karen O'Brien
A 27 yo F presents to the ED with severe RLQ abdominal pain and vaginal bleeding. She is diaphoretic and appears uncomfortable. Her vital signs are: HR 60, BP 96/55, RR 20, spo2 100%. Her boyfriend states she had a positive pregnancy test at home. Bedside transabdominal US shows no IUP, but transvaginal reveals the following. What's the diagnosis? (scroll down for answer)
Answer: Ectopic Pregnancy
- 2% of all pregnancies; leading case of maternal death in 1st trimester
- 96% occur in fallopian tubes
- Usually presents with first trimester bleeding and/or abdominal pain
- Don't forget about heterotopic pregnancy, especially in IVF!
- hCG rises abnormally in these patients (<35% every two days in ectopics)
- Evaluate for free fluid in pelvis as well to assess for rupture, as these patients can become hemodynamically unstable
- Give Rhogam if patient is Rh negative
- US shows a complex extraovarian adnexal mass in 89% cases; can also see a tubal ring (echogenic ring surrounding unruptured ectopic pregnancy- 95% PPV for ectopic)
- Unstable patient--> immediate GYN consult
- If hCG is above discriminatory zone (~3,500), TVUS does not show IUP and you still have high clinical suspicion for ectopic --> consult GYN
- If patient is hemodynamically stable, and TVUS is nondiagnostic see flowchart below for management (source: UptoDate)
I, U, Strauss A, Tinelli A, Malvasi A, Jonat W, et al. Clinical diagnosis and treatment of ectopic pregnancy. . 2013; 68:571-581.
Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Gynecol. 2004 Jul;104(1):50-5.
Atri M, Leduc C, Gillett P, Bret PM, Reinhold C, G, Aldis AE, Thibodeau M. Role of sonography in the diagnosis and management of ectopic pregnancy. Radiographics. 1996 Jul;16(4):755-74
Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Reevaluation of discriminatory and threshold levels for serum β- in early pregnancy. Gynecol. 2013 Jan;121(1):65-70.