WIDI - R1) Abdominal pain and vaginal bleeding in a patient who missed her menstrual cycle

R1) Abdominal pain and vaginal bleeding in a patient who missed her menstrual cycle

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with abdominal pain and vaginal bleeding.
Review the DDx considerations in a patient with abdominal pain and vaginal bleeding.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with abdominal pain and vaginal bleeding.

History

A 36-year-old female presents to the ED due to sudden onset lower abdominal pain that has worsened in severity over the past day, a four-day history of spotting blood per vaginam, and dizziness. She received treatment with in vitro fertilization about six weeks ago and has missed her most recent expected menstrual cycle. She reports a 15-pack year smoking history.

Physical Exam

BP: 110/82, HR 96, RR 20, Temp 98.6 F, O2 saturation 98%. General: anxious and uncomfortable. Abdominal exam: tenderness in bilateral lower abdominal quadrants. The abdominal tenderness is particularly pronounced in the right adnexal region. Vaginal exam: presence of blood in vaginal vault.

Labs

Serum quantitative b-HCG: 1,600mIU per mL

Provisional Diagnosis

Select the Dx you believe is most appropriate

Normal Pregnancy

Pelvic Inflammatory Disease

Acute appendicitis

Tubo-ovarian abscess

Ectopic Pregnancy

This patient most likely has ectopic pregnancy considering the risk factors (advanced maternal age, IVF treatment, smoking), presentation (right adnexal and cervical motion tenderness, dizziness, vaginal bleeding), and laboratory findings (positive pregnancy test).

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient requires urgent workup for their condition.

First Imaging Study

What is the first imaging study you will order?

Abdominal CT

Abdominal MRI

Transvaginal Ultrasound

The transvaginal ultrasound is the best initial imaging modality to evaluate for ectopic pregnancy. It avoids radiation exposure and can evaluate uterine and fallopian anatomy, abdominal/peritoneal free-fluid/blood, and the presence and location of ectopic pregnancy.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Abdominal ultrasound

There is a gestational sac located in the uterus.

Yes

There is no intrauterine pregnancy identified.

There is a gestational sac located in the right adnexa.

Yes

There is a gestational sac measuring 1.1cm in the right adnexa.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

MRI pelvis

CT pelvis with IV contrast

CT pelvis without IV contrast

Abdominal ultrasound

None

No further imaging is needed as the diagnosis is confirmed with the ultrasound.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Ruptured ectopic pregnancy

Nonruptured ectopic pregnancy

Pelvic Inflammatory Disease

Intrauterine Pregnancy

This patient’s clinical presentation, lab results, and ultrasound findings are consistent with a non-ruptured ectopic pregnancy.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 36-year-old female presenting with non-ruptured ectopic pregnancy. Given the small sac size (<4cm), lack of fetal heart rate, low b-HCG (≤5000mIU/mL), and hemodynamic stability, the patient may undergo a trial of methotrexate. If the ectopic pregnancy ruptures, surgical intervention, such as a laparoscopic salpingectomy, may be indicated.

Lessons Learned:
- Ectopic pregnancy is more likely to occur in older patients of childbearing age. Other risk factors include prior ectopic pregnancy, endometriosis, IVF treatment, certain STI’s, pelvic inflammatory disease, tubal surgery, and presence of an IUD.
- The diagnosis should be suspected in a patient with positive pregnancy test, vaginal bleeding, and lower abdominal pain. These findings are certainly nonspecific and occur in other conditions, including IUP. However, ectopic pregnancy is a “cannot miss” diagnosis.
- Transvaginal ultrasound is the imaging modality of choice and should be used to evaluate uterine and adnexal anatomy to assess for presence of ectopic pregnancy. An extrauterine gestational sac or echogenic heterogenous mass confirms the diagnosis when paired with physical exam, presentation, and lab findings.

Socioeconomic Factors:
- Ectopic pregnancy and related death are persistently higher in African American women and other racial/ethnic minorities.
- Women from all racial/ethnic minority groups were significantly more likely than white women to experience at least one complication during treatment, such as the need for a blood transfusion, and were more likely to experience a longer hospitalization.
- Among those with ectopic pregnancy who required surgical intervention, uninsured women have less frequently undergone tubal conserving surgery (salpingostomy).

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Thomas Kent, MS2 - Content Contributor
Alexandria Hotop - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator