A 29-year-old female presented with intense back and pelvic pain for twelve hours. Ultrasound revealed no intrauterine gestational sac but moderate free fluid in the pelvis. Given her history of pregnancy and pain, ectopic pregnancy was considered the leading differential diagnosis. She underwent surgery and pathology confirmed an ectopic pregnancy. Follow up CT after surgery found no complications and her symptoms had resolved.
2. Patient History : 29 year old female LMP : January 11, 2010. Positive home pregnancy test Intense back and pelvic pain for twelve hours prior to presentation.
3. Exams / Procedures ordered: Pelvic ultrasound February 2010 to evaluate for intrauterine pregnancy versus ectopic pregnancy Status post surgery to remove ectopic pregnancy, CT for increased abdominal pain / pressure.
4. Ultrasound Findings: Transabdominal ultrasound: No intrauterine gestational sac visualized. Moderate amount of free fluid in the cul-de-sac, homogeneous in nature, possibly consistent with hemorrhage. Uterus normal in size measuring 4.2 cm x 4.3 cm. Right ovary is normal in echotexture, size measuring 2.3 cm x 2 cm x 2.6 cm. Moderate amount of free fluid visualized adjacent to the right kidney. Transvaginal ultrasound: No intrauterine gestational sac visualized. Moderate amount of free fluid in the cul-de-sac. Uterus is normal in echotexture and size measuring 8.1 cm in length. Ovaries are normal in echotexture and size, the left measuring 2.1 cm x 2.8 cm x 3.7 cm and the right measuring 2.2 cm x 2.1 cm x 2.7 cm. Follow-up recommendations: Given patient's history of pregnancy with pain and moderate free fluid in the pelvis, ectopic pregnancy is leading differential consideration. Correlation with beta HCG level and OB/GYN consult is recommended.
9. Differential diagnosis discussion : Hydrosalpinx, pyosalpinx ruled out by positive pregnancy test.Spontaneous abortion ruled out by positive pregnancy test.Blighted ovum ruled out by lack of intrauterine gestational sac.Endometrioma is ruled out by normal endometrial stripe seen in transvaginal exam.Ovarian neoplasm ruled out by visualization of normal ovaries by transabdominal and transvaginal exams.
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11. 95-97% of ectopics are in the fallopian tubes, usually isthmus or ampullary. Also can be found within the ovary, on the peritoneal surface (abdominal pregnancy), and on the broad ligament.
12. Incidence of ectopic pregnancy is approximately 70,000 in the United states alone.
13. Can rarely (1/4000-1/8000) have a concomitant intrauterine and extrauterine pregnancy, called a heterotopic pregnancy.
14. With true ectopic, the endometrial stripe can appear normal, thickened, or contain decidual cysts or pseudogestational sac.
15. The differential diagnosis of a positive BhCG included a normal intrauterine pregnancy, an abnormal intrauterine pregnancy, and an ectopic pregnancy. Must identify intrauterine pregnancy to confidently exclude ectopic.
22. The identification of an intrauterine pregnancy eliminates the possibility of ectopic pregnancy except in high risk populations such as assisted reproduction.
