Case: 153

Ectopic Pregnancy

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History: 23 yo female with 4 day history of pelvic pain and vaginal bleeding. Had beta-HCG at outside institution of 1217 at initial presentation and now has beta-HCG of 1319. Had "negative" US at initial presentation also.
Solution: Ectopic pregnancy is a common problem in which the pregnancy begins development in a position outside the uterus. 90+% of the time these occur in the fallopian tubes, but they can also occur in the peritoneum, in the ovary, and in the cervix. The presentation is variable, but often includes pain, bleeding, and if there has been rupture, signs of blood loss. US evaluation requires a thorough evaluation of the endometrium to look for an intra-uterine pregnancy (heterotopic pregnancies are rare, especially if there is not history of fertility drugs), evaluation of the abdomen for free fluid (which can represent hemorrhage as seen in this case), and evaluation of the adnexa to see if the ectopic pregnancy can be identified (this may not be possible). The identification of significant free fluid as seen in this case can indicate hemorrhage and may be an indication for surgery. Otherwise, these can often be treated medically with methotrexate.

Questions

All of the following result in an increased risk for this process EXCEPT:
  • Smoking
  • Endometriosis
  • Family h/o ovarian cancer
  • Pelvic Inflammatory Disease
  • In utero DES exposure
This patient will likely be managed medically.
False
What is the most likely diagnosis? Please be very specific
Ectopic pregnancy with rupture and intra-abdominal hemorrhage.