Ultrasound Case 029

Presentation

A 32 year woman presents with severe lower abdominal pain and shock in early pregnancy. She has had vaginal bleeding. You consider the differential diagnosis and whilst resuscitation is commenced and gynaecology called you put the probe on her abdomen.

View 2: Longitudinal view of the uterus / pelvis

Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: RUQ view

There is a large amount of anechoic free fluid in the RUQ both below the hepatic margin and above its curved anterior surface. In this case this is very likely to be blood.

The gallbladder is also seen in the rapid sweep of the transducer over the RUQ.

Image 2: Longitudinal view of the uterus / pelvis

The uterus is empty. Surrounding it is heterogeneous blood clot. At 10 o’clock to the uterus is an extrauterine gestation sac. It has the typical echogenic decidual ring and contains a yolk sac and small foetal pole of approximately 6 weeks gestation.

Key to Image 1:  LITFL Top 100 Ultrasound 029 03
Key to Image 2

Image 3: Intra-operative video of the ectopic

Image 3: Video of the ectopic which was managed with a laparoscopic salpingectomy. Ectopics can bleed rapidly – like this. The purple rounded tubal ectopic is seen adjacent to the pink uterine fundus. Note the blood clot in the Pouch of Douglas posteriorly.


CLINICAL CORRELATION

Ruptured 6 week ectopic pregnancy.

Ectopic pregnancy is the most likely diagnosis and needs urgent consideration. The major differentials includes miscarriage with products in the cervical os causing a vasovagal reaction, miscarriage with haemorrhagic shock and a corpus luteal bleed with haemoperitoneum and viable intrauterine pregnancy.

In this case the free fluid in the RUQ with extensive clot in the pelvis confirmed intraperitoneal bleeding. The empty uterus and extrauterine gestation sac with yolk sac and embryo meant the diagnosis of ectopic pregnancy was certain. The patient went immediately to theatre and a laparoscopic salpingectomy was performed.


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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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