Tuesday 27 August 2013

Is it in the uterus?

A patient presents with sudden onset abdominal pain.  The week before, she had been seen at a private clinic to obtain a therapeutic abortion.  An ultrasound was performed there.  The patient reports that the physician told her the pregnancy was within the uterus, but that the procedure could not be performed due to her uterine anatomy.  (?was she told she had a bicornuate uterus - jw).

She was awaiting an appointment with a gynecologist at a teaching hospital on the day of presentation.

Examination revealed mild abdominal tenderness.

PoCUS images of the pelvis:

Is this pregnancy in the uterus?  The second video makes it even more clear.

Note also the free fluid in the pelvis.  On further scanning, significant free fluid was noted in the right upper quadrant also.

These images are challenging because it is somewhat difficult to determine if the pregnancy is in the uterus.  The tissue surrounding the pregnancy looks very much like uterine tissue.  However, if you look clearly you can see the bladder screen right, and the uterus with an endometrial reaction within.  Then, outside the uterus you see the pregnancy, definitely ectopic.  Another video:

The wise emergency physician remembers the following:

1) A patient with first trimester pain or bleeding has an ectopic until proved otherwise
2) One should always identify the bladder and clearly determine the outline of the uterus, not be transfixed by the pregnancy
3) One must be sure the pregnancy is inside the uterus

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