Case 15 - Misplaced Life
Author: Nish Cherian Reviewer(s): Nick Mani
A 30-year old female is triaged to the ED Ambulatory/Fast Track area with lower abdominal pain. Her LMP was 5 weeks ago and she denies any PV bleeding or discharge. She took a urine pregnancy test at home a few days prior which was weakly positive. Her vitals are stable. She is mildly tender in the lower abdomen with no guarding or peritonism.
Whilst waiting for her blood results, the nurse informs you that her pain has worsened and she is now a bit tachycardic with a BP of 100/55. The O&G team are reluctant to see the patient prior to her blood results.
You elect to perform bedside Point of Care Ultrasound with Focused Assessment for Free Fluid (FAFF) protocol.
Clip 1. RUQ
Clip 2. LUQ
Clip 3. Pelvis long axis
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Free fluid in the pelvis tracking into the pouch of Douglas with a heterogenous mass adjacent to posterior wall of uterus.
There is no definitive evidence of an intrauterine pregnancy.
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Technically this is a pregnancy of unknown location, but this would be highly suspicious for an ectopic pregnancy in the clinical context.
The echogenic mass behind the uterus may represent clot and not the actual ectopic. Transvaginal USS is more sensitive at detecting the ectopic.
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Tubal ring sign - thick hyperechoic ring around the tubal mass (in the adnexae)
Suspicious signs: absence of IUP, moderate volume free fluid in PoD, ectopic heterogenous mass
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A corpus luteum - tends to have a thinner, less echogenic wall and more cystic in appearance (more anechoic fluid), also moves with ovary and probe pressure
Ovarian cyst - well circumscribed circular cystic structure, outside uterus.
Case resolution
The patient was moved to the Resuscitation area. She dropped her BP further and was stabilised with blood products whilst the O&G team prepared her for theatre. A ruptured tubal ectopic pregnancy was confirmed in theatre and she underwent a salpingectomy. POCUS helped to facilitate earlier specialty input and mobilise the theatre team.
