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November 2007
By Phillips Perera, MD, RMDS, and Diku Mandavia, MD, FACEP, FRCPC
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Presentation:
A 20-year-old woman presents to your emergency department after experiencing lower abdominal pain for two days. She describes the pain as constant, dull, and localized to the left lower quadrant of her abdomen without vaginal bleeding or discharge. Her ob/gyn history is that she is a gravida 1, para 1 with an interval of seven weeks since the last menstrual period. She has not performed a home pregnancy test. Her blood pressure is 104/68 mm Hg and her heart rate is 84 bpm.
After the nurse informs you that a urine pregnancy test was positive and a urinalysis dip was negative, you perform a transvaginal ultrasound and obtain this image.
WHAT IS YOUR DIAGNOSIS? |
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Diagnosis and discussion:
The ultrasound image reproduced on the first page shows a uterus without evidence of an intrauterine pregnancy (IUP) or free fluid in the pelvic cul-de-sac. Those findings on focused emergency department ultrasound coupled with a positive urine pregnancy test point to a quantitative serum beta-human chorionic gonadotropin (beta-hCG) test as the next step.
The commonly defined threshold for visualization of an IUP is that its features should be apparent on pelvic sonography when the serum beta-hCG is 1500 to 2000 mIU/ml or higher. This patient’s beta-hCG returns at 30,000 mIU/ml, prompting a high degree of suspicion for ectopic pregnancy. An ob/gyn consult is in order. In this situation, some institutions would prefer a comprehensive ultrasound from the department of radiology or ob/gyn in parallel with the formal consultation. However, an ectopic pregnancy more often than not implants itself in a fallopian tube, making it possible that an emergency physician reasonably skilled in pelvic sonography may detect it on bedside exam. You scan out to the patient’s left adnexa and visualize a thickened tubal ring with a fetal pole inside, establishing the definitive diagnosis of ectopic pregnancy. |
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Dr. Perera is an assistant clinical professor of emergency medicine at Columbia University College of Physicians and Surgeons and Weill Cornell Medical College and director of emergency ultrasound at New York Presbyterian Hospital in New York City. Dr. Mandavia is a clinical associate professor of emergency medicine and director of emergency ultrasound at Los Angeles County-USC Medical Center and an attending staff physician at Cedars-Sinai Medical Center in Los Angeles.
Emerg Med 39(11):23-4, 2007
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