Case 27: Abdominal Pain

FEBRUARY MYSTERY: ABDO PAIN

A woman in her mid 30’s presents with lower adbominal pain for 2 days accompanied by light bleeding. She has no other associated symptoms and cannot remember her LMP. Her pregnancy test comes back positive. Her transvaginal ultrasound is shown below.

View image and read questions below.  Answer, discussion and excerpt from Quick Essentials Emergency Medicine follows

Note: Image courtesy of Julie Vajnar, PA-C

Is this a normal pregnancy?

What is the most likely diagnosis?

What are the pitfalls to avoid?

Scroll down for case answer

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Answer: Pseudosac with Ectopic Pregnancy

Pseudosacs occur in up to 20% of ectopic pregnancies. As opposed to a normal gestational sac, a pseudosac tends to fill the entire endometrial cavity, lacks the “double ring” sign and lacs a yolk sac or embryo.

“QUICK ESSENTIALS: EMERGENCY MEDICINE“

Ectopic : Pain can be absent to severe, constant or crampy, in groin or back
Ultrasound: Bedside if sick, #1 finding:empty uterus. 20% ectopics also ĉ cyst.
W/U: T&C, IVx2, OR, Rhogam if Rh negative
Heterotopic: Rare unless on fertility drugs or in-vitro fertilization, etc.
HCG: 99.4% sensitive. If <1500 & mild sx: 48h f/u, o/w admit; if hcg<1000 worry more about ectopic.
Repeat HCG 48h later should have a >66% rise or suspicious for abnormal pregnancy
Pitfalls: Can have ectopic with: No pain, passed tissue, fever, nl HCG doubling, heterotopic, bradycardia, Urine HCG -
Rx: OR if rupture, OR or methotrexate if unruptured.
Dispo: Consider D/C home if nondiagnostic US & stable with close f/u. Repeat US & beta HCG in 48h

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Methotrexate: Prep: US, CBC, baseline LFT’s

Sides: Can mimic rupture. AP, vomiting. If comes to ED, repeat the ultrasound
Contras: Absolute: rupture, unreliable. Relative: yolk sac, heartbeat, size >3.5cm, higher HCG (>10K)
Dose: 50mg/meter-squared. 50% get pain. Can still rupture 6wks out with falling beta-HCG
Pain: If severe: US, CBC, NO pelvic exam. Consided admission for observation

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