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Short answer question case series: abnormal first-trimester pregnancy
  1. Alisa K Sato,
  2. Timothy B Jang
  1. Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California, USA
  1. Correspondence toDr Timothy B Jang, Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, 1000 W Carson Ave, D-9, Torrance, California 90509, USA; tbj{at}ucla.edu

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Case vignette

A 31-year-old woman, gravida 3 para 2, at about 8 weeks pregnant presents with lower abdominal pain. On examination, her vitals are stable and she has adnexal tenderness (left > right). Her urinalysis is normal but her urine pregnancy test is positive. Her β-hCG is 1189. An ultrasound is done with the figures below.

Key questions

  1. What is your reading of this ultrasound?

  2. How does the quantitative β-hCG affect your interpretation?

  3. What are her treatment options?

  4. What should her disposition be?

1. Figure 1A is a transabdominal longitudinal view showing free fluid in the posterior cul-de-sac behind the uterus with no evidence of an intrauterine pregnancy (IUP). This is an overall good view since it shows you the related anatomy of the bladder, cervix/vagina, uterus and both cul-de-sacs. Figure 1B is a transvaginal transverse view of the uterus. Once again, we can see free fluid behind the uterus with no evidence of an IUP (no gestational sac, yolk sac or fetal pole). Figure 1C is a transvaginal view of the left adnexa showing the ovary to the left of the screen and an adjacent, irregular solid mass. At this point, ectopic pregnancy is very high on your differential, especially if the patient is pregnant with adnexal tenderness.

Figure 1

Initial ultrasound images.

The radiologist calls with the read: ‘No IUP, but 3.5×1.7×2.3 cm heterogeneous likely left tubal adnexal mass suspicious for ectopic pregnancy with small free pelvic fluid’.

2. The quantitative β-hCG does not change the management of this patient. The discriminatory level, or the level of hCG at which an IUP should be visible on transvaginal ultrasound is institution dependent and usually between 1000 mlU/l and 2000 mlU/l.1 Our patient had a β-hCG of 1189 (our discriminatory level is 1000), and therefore we should see evidence of an IUP. In the setting of an adnexal mass, free fluid in the pelvis, and no IUP, this is most definitely an ectopic pregnancy.

3. There are numerous treatment options for an ectopic pregnancy. Medical management with methotrexate is commonly used for smaller ectopics (<3.5 cm) in a haemodynamically stable patient with no signs of active bleeding.2 Contraindications to methotrexate are numerous and include: haemodynamic instability including rupture or ongoing bleeding, free fluid in the cul-de-sac on ultrasound, β-hCG >15 000, fetal cardiac activity, hypersensitivity to methotrexate, breastfeeding, immunodeficiency, alcoholism, blood dyscrasias, peptic ulcer disease and liver, renal or pulmonary disease.2 ,3 It is common for patients to experience mild abdominal pain 2–3 days after the methotrexate injection, but should not worsen or persist after 1 week. If methotrexate is contraindicated, the other treatment options are laparoscopy or laparotomy.

4. At this point, with such a high suspicion for an ectopic pregnancy, the patient should undergo laparoscopy or have obstetrics and gynaecology (OBGYN) exam in the emergency department. Unfortunately, this patient was started on methotrexate after phone consultation and sent home.

Case continuation

The patient returned 5 days later with increasing abdominal pain. On exam, her blood pressure was 102/65 with a heart rate of 90 with moderate left lower quadrant tenderness. A repeat β-hCG was 909 and another ultrasound was done.

Key questions

  1. What is your reading of this ultrasound?

  2. How does the quantitative hCG affect your reading?

  3. What are her treatment options?

  4. What should her disposition be?

5. Figure 2A, B, C are transabdominal views of the uterus with no IUP and an increased amount of free fluid in the posterior cul-de-sac. Figure 2D is a transvaginal sagittal view showing debris which is most consistent with haemorrhage. Figure 2E is a transvaginal view of the adnexa with the ectopic mass that has doubled in size.

Figure 2

Images from subsequent presentation.

The radiologist calls back with the read: ‘there is no IUP with significant, complex, possibly haemorrhagic free pelvic fluid. There is also a 6.2×2.8×4.4 cm mass lesion in the left adnexa suspicious for an ectopic pregnancy’.

6. Once again, the quantitative β-hCG does not alter your management. The repeat β-hCG was 909. Normally after methotrexate, the β-hCG is checked at 4 and 7 days and expected to decrease by 15%.4 Despite the fact that our patient's β-hCG did decrease appropriately, our exam and ultrasound findings are far more compelling for a ruptured ectopic.

7. At this point, the patient has failed medical treatment with methotrexate and will need surgical management. She should go for either a laparoscopy or laparotomy.4 Repeated doses of methotrexate would not be an option here.

8. Unfortunately, the patient was seen by OBGYN in the emergency department but sent home. She returned 6 h later in shock with a blood pressure of 80/40. She was ill-appearing and pale. Crystalloids and two units of blood were initiated in the emergency department and she was rushed to the operating room where they found 1 l of blood in the peritoneum with a complex adnexal mass, products of conception adherent to the bowel and profuse bleeding. They removed the tube due to severe scarring, adhesions and persistent bleeding.

In conclusion, the key teaching points of this case are: (1) a positive pregnancy test without a visualised IUP and an increase in free fluid and adnexal mass is a ruptured ectopic pregnancy until proven otherwise, (2) the β-hCG must be interpreted in conjunction with the exam and ultrasound findings, and (3) this patient should not have been sent home by the emergency physician regardless of the OBGYN consult.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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