Peer Reviewers: Lee LaRavia, DO; Dan Kaminstein, MD; Ricaurte Solis, DO
Learning Objectives:
DDX for pre-menopausal abdominal pain
Discuss use of US in the workup of the pre-menopausal female with abdominal pain
Discuss the IS characteristics/findings
Review and recent literature
Case Presentation:
Arrived to EDWR at 14:38
CC: "c/o abd pain since yesterday. denies n/v/d. denies any abd surgries. denies blood
in stool. pt states she is able to hold fluids and solids. denies pmh. pt states bp
usually runs low."
HR 97, BP 87/63, RR 17, T 36.7, SpO2 100% on RA
Triaged at 3H.
Roomed in A16 at 15:59.
37yo F with no PMH c/o lower abdominal pain for 2 days. Gradually worsening. Relieved
with Tylenol but progressively worsening since this morning. LMP 3 weeks ago which
was 3-4 days early and lighter than normal. No VB but has blood when wiping after
urination. No fevers, nausea, vomiting, diarrhea, urinary symptoms, chest pain, SOB.
No previous abdominal surgeries. Sexually active with husband, 2 prior pregnancies,
no birth control.
HR 95, BP 108/58, RR 16, SpO2 98% on RA
GEN: comfortable in bed, AOx4 HEENT: MMM, no scleral icterus ABD: Soft, mild suprapubic tenderness, ND, no masses, no rebound/guarding.
Paged OB/GYN for ruptured ectopic, hypotensive, +UPT with positive FAST.
OB evaluated patient and images and requested for TVUS. ED team was uncomfortable
with patient leaving the department for a TVUS. She was transferred to E-pod.
Repeat vitals: HR 95, BP 108/58, RR 16, SpO2 100% on RA
FAST exam repeated (~1 hour since prior).
Diagnosis and Case Disposition:
Requested OB to re-evaluate. Began transfusing 1st of 2 units cross-matched pRBC.
They agreed that patient was peri-stable and had significant abdominal free fluid
- most likely ruptured ectopic pregnancy. Taken to OR Level 1.
Patient had successful ex-lap with ~1000cc hemoperitoneum with ruptured R fallopian
tube ectopic pregnancy.
Discharged POD #1. Doing well at 5-day OB follow-up.
POCUS QA:
Images with too much depth. But good quality images of RUQ, LUQ, and suprapubic regions
(did not have concern for subxiphoid)
Suprapubic with heterogeneous matter and mild fluid.
Thickened endometrium without IUP. Mild fluid posterior to uterus.
Initially no fluid at RUQ, but failed to capture caudal pole of kidney. Significant
fluid at LUQ.
Repeat RUQ with massive fluid and floating liver.
Could have obtained better imaging of uterus to better confirm no IUP.
Literature Review:
50% of ectopic pregnancies have no risk factors.1
Presence of fluid at hepatorenal or splenorenal spaces indicates large amount of fluid
(>500cc) suggestive of large peritoneal bleed.2
Utilization of POCUS vs formal US leads to:
Faster diagnosis (15 min vs 138 min)
Faster ED door to OR time (145 min vs 243 min).3
RUQ US vs TVUS was equivocal at finding ectopic with significant hemoperitoneum (average
was 1000cc for this study). 4
TVUS may be inferior to POCUS because of TVUS ability to detect such small amounts
of pelvic fluid (8cc). 4,5
Take Away Points:
POCUS can help identify patients with ruptured ectopic pregnancy and facilitate appropriate
next-steps in resuscitation and final disposition
Ambulatory patients MAY NOT have free fluid in the RUQ when you first scan them because
they have been sitting/or standing
Complex fluid such as pus or clotted blood will have a different appearance by ultrasound
and recognizing this will help with risk stratifying patients appropriately.
It is important to fully visualize the uterus when performing a FAST exam on patient
with suspected ectopic pregnancy.
TVUS does not add anything to your patient with +UPT and RUQ/LUQ fluid
Relay to your consultants that fluid at hepatorenal or splenorenal spaces is likely
significant volume (>600cc). Communicating vital information to consults with familiar
terminology is important (i.e. “Positive FAST”). However, though we understand what
a “positive FAST” means, they may not. This is key to avoiding miscommunication during
the consultation process.
Repeat FAST scans in unstable patients can be life-saving. Do not send a patient
out of the department for an imaging study without carefully weighing the risk and
benefits of the study
References:
E. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med. 1990;19(10):1098-1103.
Mausner Geffen E, Slywotzky C, Bennett G. Pitfalls and tips in the diagnosis of ectopic
pregnancy. Abdom Radiol (NY). 2017;42(5):1524-1542
Urquhart S, Barnes M, Flannigan M. Comparing Time to Diagnosis and Treatment of Patients
with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective
Inquiry. J Emerg Med. 2022 Feb;62(2):200-206. doi: 10.1016/j.jemermed.2021.07.064.
Epub 2021 Sep 17. PMID: 34538680.
Rodgerson, J. D., Heegaard, W. G., Plummer, D., Hicks, J., Clinton, J., & Sterner,
S. (2001). Emergency department right upper quadrant ultrasound is associated with
a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Academic
Emergency Medicine., 8(4), 331–336. https://doi.org/10.1111/j.1553-2712.2001.tb02110.x
Stone BS, Muruganandan KM, Tonelli MM, Dugas JN, Verriet IE, Pare JR. Impact of point-of-care
ultrasound on treatment time for ectopic pregnancy. Am J Emerg Med. 2021 Nov;49:226-232.
doi: 10.1016/j.ajem.2021.05.071. Epub 2021 Jun 9. PMID: 34146921.
