COTW August 27th: A 34 year old female with pelvic pain and vaginal bleeding...

A 34 year old female presented to the ED 4 days prior with vaginal bleeding. UPT positive at home. Radiology department pelvic US performed, no IUP seen, beta HCG was 477.

She was discharged home with instructions for repeat studies in 48 hours. She returned to the ED  with abdominal cramping and persistent vaginal bleeding 4 days later. Repeat Beta HCG was 590.

POCUS performed:

On this first clip you see the uterus without any obvious gestational sac or sign of IUP. Notice that there is a moderate amount of free fluid within the pelvis surrounding the uterus.

On this first clip you see the uterus without any obvious gestational sac or sign of IUP. Notice that there is a moderate amount of free fluid within the pelvis surrounding the uterus.

On this next clip we see the adnexa and the first thing we see is a structure that appears to be an ovary with small follicles within it. However, adjacent to it you will notice that there is an echogenic mass that doesn’t quite appear to be part of the ovary itself.

On this next clip we see the adnexa and the first thing we see is a structure that appears to be an ovary with small follicles within it. However, adjacent to it you will notice that there is an echogenic mass that doesn’t quite appear to be part of the ovary itself.

This clip highlights the distinct areas and the mass that his highly suspicious for an ectopic pregnancy.

This clip highlights the distinct areas and the mass that his highly suspicious for an ectopic pregnancy.

She was seen by OB/GYN and opted to treat with Methotrexate and return to the ED for serial labs and follow-up. She presented again 2 days later with worsening symptoms and a larger adnexal mass. She was taken to the OR for operative management of the ectopic pregnancy. 

Learning points:

-Beta HCG normally doubles every 48 hours.

-ALWAYS ask about fertility treatments (risk of heterotopic pregnancy)

-To confirm IUP you need at minimum see a gestational sac ≥25mm with a yolk sac surrounded by ≥8mm of uterine tissue. Fetus and FHR are also great to see (in a gestational sac)

-When looking at the adnexa, be weary around the ovaries as ectopic pregnancies can look like follicles or cysts