Case vignette
31yo F p/w abrupt onset abdominal pain and vaginal bleeding.
HR 48, BP 90/70, T 36.3, RR 20, SpO2 98% on RA.
Diffuse abdominal tenderness with rebound. Active, slow vaginal bleed. Patient with cool extremities and ~3s cap refill.
Urine hCG positive.
What do you see?
Ob1 Suprapubic: free fluid superior/posterior to bladder
Ob1 RUQ: no free fluid in Morrison's pouch, however free fluid at liver tip
What do you do next?
Suspecting ruptured ectopic, you place an emergent call to ObGyn, obtain a T&S and consent the patient for blood. You suspect the patient is developing hemorrhagic shock and that she has paradoxical bradycardia. You order a fluid bolus while waiting T&S results, however her BP begins to drop to systolics 70s and you immediately initiate O- blood and TXA.
She is whisked away to the OR, where a ruptured ectopic is confirmed and a L sided salpingo-oophorectomy performed. When her blood type returns B-, you ensure OB is aware and that Rhogam is given. The patient is stabilized and recovers. Interestingly, her quantitative hCG returns at only ~200.
Teaching points. POCUS can rapidly help diagnose ruptured ectopic -- if this is high on your differential, no need to wait for radiology performed ultrasound! In pregnant patients without confirmed IUP, abdominal pain, vaginal bleeding, a positive FAST is highly concerning for ectopic and merits immediate operative intervention.
Pearls:
- A paradoxical bradycardia may accompany ruptured ectopic, even in the setting of hemorrhagic shock. This may falsely dissuade you from the correct diagnosis of shock and rapid/aggressive resuscitation. Hemoperitoneum-induced vagal nerve stimulation has been theorized as a cause for this.
- Remember that patients with risk factors for heterotopic pregnancy (namely in vitro fertilization, or IVF) can have an IUP and ectopic concurrently.
- While discussion of discriminatory zones is outside the scope of this post, it is worthwhile to note the utility of the discriminatory zone has recently been questioned. While an hCG > 1,500 with no IUP seen on trans-vaginal ultrasound is concerning, hCG < 1,500 without visualized IUP should not reassure against ectopic. Many (in fact, possibly most) ectopics rupture before hCG reaches the discriminatory zone. Do not let a low hCG without a visible IUP dissuade you from the diagnosis. For further reading, see this excellent post: https://canadiem.org/%CE%B2-hcg-discriminatory-zone-suspected-ectopic-pregnancy/.
Residents: Dr. Ryan Doumani
Ruptured Ectopic
April 2020