COTW 2/14/22: 36 year old female with abdominal pain

A 36 year old female, G7 P2 A5, presented to the ER with 2 days of left side abdominal pain. Patient denies systemic symptoms. Patient’s history is pertinent for 5 medically induced abortions. Vital signs: HR 110, BP 110/50, RR 18, T 98.5 O2 100%. Urine pregnancy test resulted as positive. Patient was comfortable appearing with minimal tenderness along left lower quadrant/pelvic region. Abdomen was non-acute. Waiting for the serum hCG . . .

Point of care ultrasound was performed:

An extra-uterine structure is seen on the right side of the screen. It appears to be attached to the uterus. Image was obtained using the curvilinear probe.

Using the high frequency probe, the structure in question was amplified. Not only a gestational sac was confirmed, a yolk sac was revealed! No fetal pole visualized.

Patient was diagnosed with an ectopic pregnancy prior to serum b-hCG results; level measured 6,000 mIU/mL. Remaining blood work was unremarkable. Patient was transferred to sister hospital for Ob-Gyn evaluation and management.

ECTOPIC PREGNANCY

Ectopic pregnancy (EP) is defined as an embryonic implantation outside of the endometrial cavity. EP account for 2% of pregnancies. It’s occurrence increases significantly with fertility treatments. Approxamitely 50% of patient

Locations:

Tubal

• Ampullary: 70%

• Isthmus: 12%

• Fimbria: 11%

• Interstitial/cornual: 2%

  • Mortality x2 in comparison with all other tubal EP

Ovarian: 3%

Abdomen: 1%

Cervical: 1%

Risk Factors for Ectopic Pregnancy:

Previous EP

Hx of tubal, pelvic or abdominal surgery

PID

Endometriosis

Tobacco use

STD

Age > 35

Work up:

Serum b-hCG, CBC, type and screen, metabolic panel

Clinical Presentation:

Abdominal/pelvis pain, vaginal bleeding, syncope

Treatment:

Indications for surgical intervention

• Medical treatment failure

• Patient is not suitable for medical therapy

• Hemodynamic instability

• Heterotopic pregnancy

Medical management (Methotrexate)

• Indicated: stable hemodynamics, b-hCG < 5,000, unruptured ectopic, no fetal cardiac activity, appropriate follow up available, normal hepatic/renal function, WBC >2,000 and PLT >100,000.

• Contraindicated: unstable hemodynamics, b-hCG >5,000, fetal activity, evidence of ruptured EP (free fluid).

RUPTURED ECTOPIC PREGNANCY: APPROACH

+ pregnancy test -> ectopic is possible? -> no IUP -> FAST positive -> call Ob-Gyn patient needs the OR!!

Back to our case…

Patient’s b-hCG level resulted as 6,000. Based on current guidelines patient was not a candidate for medical treatment. Patient remained hemodynamically stable throughout her ED visit. Ob-Gyn was consulted and patient underwent surgical intervention with an uneventful hospitalization.

Key Points:

• Always maintain high level of suspicion for ectopic pregnancy in every female of bearing age with abdominal pain and positive pregnancy test.

• Positive b-hCG + empty uterus -> ectopic pregnancy until prove otherwise

• Positive b-hCG + ectopic + free fluid -> ruptured ectopic! Call Ob-Gyn!!!