UCONN Emergency Medicine Interest Group

Ultrasound Case #3

In RADIOLOGY on June 16, 2011 at 8:43 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: RLQ abdominal pain.

HPI: 25 yo female presents to ED with severe right lower quadrant abdominal pain beginning yesterday.  LMP about 7 weeks ago.  Denies vaginal discharge or bleeding.  No history of abnormal pap smears, STI’s or previous pregnancies.  Sexually active without protection.

FH: denies alcohol, smoking or drug use.

PE: Afebrile. VSS.  Abdomen tender to palpation suprapubic, right and left lower quadrants.  Pelvic exam with bilateral adnexal tenderness.  Cervical os closed.

Labs: Urinalysis negative for infection.  Urine pregnancy positive. H/H stable.  Quantitative B-hCG: 83,000.

Bedside U/S: (see beginning of post for 1st still image): click for video.

What is the next step in management? (click below to see answer below the fold)

Exploratory laparotomy.

Above picture and video shows longitudinal view of uterus with a thickened endometrial stripe, multiple nabothian cysts and moderate amounts of free fluid in the pelvic cul-de-sac.  No IUP seen.

Formal U/S: No definitive IUP.  Multiple nabothian cysts.  No adnexal masses.  Moderate amounts of free fluid.

Plan: Patient admitted to OB/GYN and taken to the OR for exploratory laparotomy.  Patient was found to have an ectopic pregnancy in the right fimbria portion of the fallopian tubes.

Teaching Points

If suspecting an ectopic pregnancy, be sure to scan completely through uterus and both adnexa.  Look for:

  • A tubal ring
  • A complex adnexal mass and ‘ring of fire’ when color Doppler is placed over the mass
  • Free fluid in the pelvic cul-de-sac

References

  • Gurel, S. Role of sonography in the diagnosis of ectopic pregnancy. J of Clinical Ultrasound. 2007; 35:509-517.
  • Kaplan, B. Ectopic pregnancy: Prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996; 28:10-17.
  • Mateer, J. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy.  Ann Emerg Med. 1996;27:283-289.
  • Reardon, R. First trimester pregnancy. Emergency Ultrasound. McGraw-Hill: New York, 2003;239-275.
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