Ruptured ectopic

Written by: Dr. Callie Winters

Edited by: Dr. Joann Hsu

The case:

32 yr old female patient G7P3 hx of L salpingectomy for ruptured ectopic pregnancy 1 yr prior presents with 1 day of severe lower abd. pain.

  • + home pregnancy test, LMP was 1 month ago

  • No N/V/D, vaginal bleeding or discharge, no fever, no urinary complaints

  • V/S: BP 110/70 (had been 97/61 prior to presentation), HR 88, RR 18, Temp 36.8º C, spO2 99%

Exam: Uncomfortable appearing, + diffuse abdominal tenderness w/ voluntary guarding and mild distension

Labs: Beta HCG : 54,683.0, Rest of labs WNL

Bedside ultrasound showed:

RUQ view with free fluid

Saggital view of the uterus with more free fluid and no IUP

A concerning extrauterine pregnancy with a visible fetal heart rate! :O

A closer look at the extrauterine pregnancy

POCUS interpretation:

  • Dr. Hannah Park: “L tubal ectopic pregnancy with a heartbeat, measuring approximately 7 weeks, along with large free fluid in the LUQ and pelvic, smaller free fluid in the RUQ” 

Formal pelvic US report:

  • “Findings consistent with ruptured ectopic pregnancy. There is a live gestation in the left adnexum separate from the left ovary. Moderate amount of free fluid in the abdomen and pelvis.”

Ectopic pregnancy

  • Epidemiology: 1-2% of all pregnancies

  • Risk as high as 18% with 1st Trimester Bleeding

  • Risk Factors:

    • IVF (2-8%)

    • Prior ectopic

    • Tubal injury/surgery (including ligation)

    • PID

    • IUDs

    • Smoking

    • Endometriosis/endometrial injury

    • Salpingitis isthmica nodosa

    • Previous placenta previa

    • Uterine abnormalities

    • Past spontaneous or induced abortions***

    • Advanced maternal age

    • Hx of subfertility

    • 93-97% are tubal (ampullary are most common)

    • Vast majority occur within reproductive tract, but abdominal or scar ectopic pregnancies are rare but possible

  • Early pregnancy beta HCG should double every 48 hrs -> slower doubling rate in ectopic pregnancy

  • This could also represent another form on non-viable pregnancy

  • Beta HCG can be negative in ectopic pregnancy, although very rare.

Other ultrasound findings concerning for ectopic pregnancy

  • Uterus:

    • Empty Uterine cavity ***except in heterotopic pregnancy*** (co-existing ectopic in 1-3:100 IVF pregnancies vs. 1:30,000 non-IVF)

    • Pseudogestational sac/decidual cyst

    • Decidual cast

    • Thick echogenic endometrium

  • Tubes/Ovaries:

    • Simple adnexal cyst (10% chance)

    • Complex extra-adnexal cyst/mass: 95% chance (intra-adnexal cyst/mass more likely corpus luteum

    • Solid hyperechoic mass (non-specific)

    • Tubal ring sign (95% chance if seen)

    • “ring of fire sign” on color doppler (can also be seen in a corpus luteum)

    • Live extra-uterine pregnancy (i.e. FHR) is 100% specific

  • Peritoneal Cavity:

    • Free fluid (of note: not specific for rupture, seen in 37% of intact tubal ectopics

    • Live extra-uterine pregnancy

Heterotopic pregnancy!! Remember - this can happen particularly in IVF patients

Back to the case:

  • OBGYN was consulted in the ED (patient was moved to trauma bay after US)

  • 2 large bore IVs were placed and 1 unit pRBCs was started (also started on IVFs and morphine for pain control)

  • Admitted directly to the OR for L ectopic pregnancy

  • Evacuated 1500 cc of hemoperitoneum in the OR (they had to convert to open from initial laparoscopic approach)

  • Received repeat L salpingectomy of the tubal remenant where ectopic had occurred

  • D/C’d 2 days after initial presentation

  • Recovering well with outpatient followup

Happy scanning!

Resources

  • Gaillard F, Le L, Sharma R, et al. Ectopic pregnancy. Reference article, Radiopaedia.org (Accessed on 02 Dec 2024) https://doi.org/10.53347/rID-1258

  • Baker M, dela Cruz J. Ectopic Pregnancy, Ultrasound. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482192/

  • Hu Z, Li D, Chen Q, Chai W, Lyu Q, Cai R, Kuang Y, Lu X. Differences in Ectopic Pregnancy Rates between Fresh and Frozen Embryo Transfer after In Vitro Fertilization: A Large Retrospective Study. J Clin Med. 2022 Jun 13;11(12):3386. doi: 10.3390/jcm11123386. PMID: 35743455; PMCID: PMC9225258.

  • Dart RG. Role of Pelvic Ultrasonography in Evaluation of Symptomatic First-trimester Pregnancy. Annals of Emergency Medicine. 1999;33(3):310-320. doi:10.1016/S0196-0644(99)70368-9

  • Anderson J, Ghaffarian KR. Early Pregnancy Diagnosis. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556135/

Booth EM