Emergency – Long case 3

39-year-old female:
* Known with uterus myomatosus
* Pregnant 8 weeks

Presents in the ER with vaginal blood loss. Sky high beta-HCG. The gynaecologist could not find a pregnancy with abdominal or endo-vaginal ultrasound.

Is it an ectopic pregnancy?

My ultrasound: Very large intramural myomas, one with some central necrosis. In the lower right abdomen thick-walled cystic structure connected to fallopian tube.

Additional CT with intravenous contrast shows thick-walled extra-adnexal complex cyst connected to the right adnex, consistent with tubal ectopic pregnancy. Furthermore, two very large intramural myomas, which compress the uterine cave.

Ectopic pregnancy

Follow-up: The patient received methotrexate, but it did not work. Then, therapeutic laparoscopic removal of the ectopic pregnancy was performed, with sparing of the tube and ovary due to our knowledge of CT where the exact location was.

Often ectopic pregnancies present with vaginal blood loss, beta-HCG > 6.000-15.000 mIU/mL and on ultrasound often free fluid in the peritoneal cavity.

Teaching point: The absence of free fluid does not exclude ectopic (tubal) pregnancy.
Teaching point: Always offer to do a second look ultrasound, even if the gynecologist already performed an ultrasound.
Teaching point: Uterus myomatosus does NOT increase the risk of ectopic pregnancy.

The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include the following:

* Ruptured corpus luteum
* Exophytic corpus luteum of pregnancy
* Intrauterine pregnancy
* Incidental adnexal mass
* Appendicitis (negative beta-hCG)

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