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• W4386585802 abstract "Figure: abdominal pain, hypotension, diagnosticsFigureA 28-year-old woman presented to the emergency department by ambulance at 3 a.m. She arrived with severe abdominal pain that woke her from sleep 30 minutes prior to arrival. The pain was in her lower abdomen and radiated to her rectum. She had never had pain like this before, said she was not pregnant (last menstrual period one month earlier), and had no urinary or vaginal symptoms. She was doubled over in pain with a peritonitic abdomen (not peritoneal), and she was tachypneic (32 bpm) and hypotensive (90/60 mm Hg), but she had a normal heart rate (96 bpm). The patient had a history of treatment for gonorrhea and chlamydia, but otherwise no other pertinent medical or surgical history. She was taking no medications. Given the patient had hypotension and abdominal pain, a bedside ultrasound was quickly performed, which led to the immediate diagnosis and treatment. What is this patient's diagnosis? Find the case discussion on the next page. Diagnosis: Heterotopic Pregnancy The FAST exam showed free fluid, and the physician saw not only an approximately 10-week intrauterine pregnancy with cardiac activity but also an extrauterine pregnancy and a large corpus luteal cyst. Her blood pressure improved with blood products, but her heart rate dropped to 56 bpm and her abdominal pain worsened. Pain management was increased, and the patient was taken to the OR within 20 minutes of arrival. Heterotopic pregnancies are rare and were noted in one in 30,000 pregnancies before the advent of assisted reproductive technology (ART), which increased the rate to one in 3900 pregnancies. Significant variables related to ART contribute to the increased risk: underlying tubal disease, higher levels of hormones, and a high number of transferred embryos. This patient's risk likely stemmed from her history of multiple episodes of pelvic inflammatory disease (PID) and tubal adhesions. Her operative note mentioned perihepatic lesions consistent with Fitz-Hugh-Curtis syndrome. Most heterotopic cases consist of one intrauterine pregnancy (IUP) and one extrauterine pregnancy, with 90 percent located in the fallopian tube. Unfortunately, many cases are missed because ectopic pregnancy is not considered once an intrauterine pregnancy is identified. This also means that the diagnosis is usually made later in gestational age when symptoms such as abdominal pain or vaginal bleeding occur due to rupture. This patient's abdominal pain was not well differentiated on arrival, however, because she was hypotensive. The emergency physician's first test was the most appropriate to sort out what to do next. The ultrasound showed free fluid in Morison's pouch. Rather than continue in the normal order of the FAST exam, the physician scanned through her pelvis to evaluate for potential bladder pathology (acute rupture after sleeping with a full bladder) or pregnancy. The pregnancy was identified quickly, as were the extrauterine pregnancy and corpus luteal cyst. If only the IUP had been seen, the ectopic pregnancy may have been excluded from the differential and delayed the diagnosis and treatment.FigureFigureThe treatment for a heterotopic pregnancy is operative. The least invasive and site-specific surgery is preferred to preserve the IUP. Methotrexate is contraindicated due to the presence of a viable IUP. A patient will need a repeat ultrasound one to two weeks after surgery to assess the viability of the IUP. Unfortunately, patients with heterotopic pregnancies have a higher risk of spontaneous abortion. The patient in this case was taken to the OR emergently for a salpingectomy and evacuation of one liter of blood in her abdomen. She followed up after two weeks and had a reassuring obstetric ultrasound showing continued cardiac activity. This case highlights not only a rare diagnosis but also the importance of using bedside ultrasound to assess hypotension rapidly and begin to limit the differential in a woman with severe abdominal pain. The ultrasound findings in this case led to the quick diagnosis, blood administration, and OR activation. Dr. Eutermoseris an assistant professor of emergency medicine at Denver Health and University of Colorado Hospital." @default.
• W4386585802 created "2023-09-11" @default.
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• W4386585802 date "2021-11-01" @default.
• W4386585802 modified "2023-09-29" @default.
• W4386585802 title "Quick Consult" @default.
• W4386585802 doi "https://doi.org/10.1097/01.eem.0000800500.09415.13" @default.
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