Early Pregnancy Complications No. 1

On completing this case study, reading associated articles and answering related questions, you will;

• Expand your knowledge on the spectrum of symptoms and signs of ectopic pregnancy presentation,
• Become familiar with the role of diagnostic tools and in particular the appearance of ectopic pregnancy on ultrasound,
• Develop a critical approach to evaluating the quality of ultrasound images,
• Understand the advantages and disadvantages of different treatment options,
• Be able to reflect and test the acquired knowledge.

Case History

A 36 year old nulliparous lady presents to A+E with worsening abdominal pain. She found earlier that morning she was pregnant (positive urine dip stick). This was an unplanned pregnancy. Later that morning she fainted after having a shower. Her abdominal pain became worse and was now associated with loose stools. There was no nausea or vomiting. Her husband called an ambulance as he was concerned about her condition.

On arrival in accident and emergency she was haemodynamically stable. She was well perfused, her abdomen was tender and there was no peritonism. There was no vaginal bleeding and bimanual examination was generally tender. Her Hb was 99g/L and her HCG was 1765IU/L. An ultrasound scan was requested.

Diagnosis: Ectopic pregnancy

Management Issues

In a haemodynamically unstable patient with suspicion of ectopic pregnancy, prompt surgical intervention is the management of choice.

In a stable patient, ultrasound should be the first-line imaging modality. If an intrauterine pregnancy is confirmed, other causes for the presentation should be considered such as corpus luteum accident, pelvic inflammatory disease or other non-gynaecological causes.

Discussion

Ectopic pregnancies may present with no risk factors and only subtle clues in the history. A high index of suspicion is needed so as not to delay the diagnosis. Healthy women compensate haemodynamically, even with significant intra-abdominal bleeding, and maintain their BP but may become unstabe rapidly.

An ultrasound performed in A+E would have significantly raised the index of suspicion of a ruptured ectopic pregnancy (free fluid + positive pregnancy test + pain). Transvaginal ultrasound

is both sensitive and specific for the diagnosis of ectopic pregnancy.

Ultrasound Features in this Case Include

Anteverted uterus with no evidence of an inter-uterine pregnancy (no gestational sac) and a thickened endometrium only

Uterus surrounded by free fluid, both anterior to it and in the pouch of Douglas

Floating loops of bowel in the pelvis

Visible internal iliac vessel adjacent to the ovary partly highlighted with colour flow Doppler in Figure 2.

Adnexal mass adjacent to the ovary showing abnormal vascularity.

Further Reading

Green Top Guideline No. 21, Management of tubal pregnancy. www.rcog.org.uk

The accuracy of transvaginal ultrasound for the diagnosis of ectopic pregnancy prior to surgery. Condous et al. Go to Free article: >> Human Reproduction Vol. 20, No. 5 pp. 1404–1409, 2005