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Within Normal Limits

Ultrasound Pinpoints Cause of Vaginal Bleeding

Irani, Zeenia MD; Patel, Himanshu MD; Patel, Shivani MD

doi: 10.1097/01.EEM.0000488832.70208.55
Within Normal Limits

Dr. Iraniis a third-year radiology resident at Westchester Medical Center in Valhalla, NY, whereDr. Himanshu Patelis the director of musculoskeletal radiology at Westchester Medical Center in Valhalla, NY, and an assistant professor of radiology at New York Medical College. Dr. Shivani Patelis an emergency physician at Stamford (CT) Hospital.

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A 28-year-old woman G3P1011 presents to the emergency department with heavy vaginal bleeding for one week with new onset of right lower abdominal pain: 8/10. Her last menstrual period was approximately six weeks prior to presentation.

She also complained of fever, dysuria, chills, and nausea. Her beta human chorionic gonadotropin (beta HCG) level was 1888.

A transvaginal pelvic ultrasound was done of the right ovary that demonstrated a large heterogeneous extra-adnexal mass with a thickened peripheral wall adjacent to the right ovary containing a yolk sac and fetal pole. (Image 1.) A positive fetal heart rate measuring 122 beats per minute was seen. (Image 2.) Gray-scale transabdominal ultrasound of the pelvis demonstrated absence of an intrauterine gestational sac. (Image 3.) A Doppler transvaginal ultrasound demonstrated hypervascularity to the extra-adnexal mass, compatible with a “ring of fire” sign. (Image 4.)

The patient was diagnosed with a right tubal ectopic pregnancy. A diagnosis of ectopic pregnancy should be considered in any woman of childbearing age who presents with abdominal pain or vaginal bleeding. Early diagnosis of ectopic pregnancy is essential to decrease morbidity and mortality. Pelvic sonography with correlation to quantitative beta human chorionic gonadotropin (beta HCG) levels is crucial for initial assessment for ectopic pregnancy.

An ectopic pregnancy occurs when a fertilized ovum implants anywhere outside the uterine cavity. The most common site of ectopic pregnancies is within the fallopian tube (95%), most commonly in the ampulla (70%) or isthmus (12%) and less commonly in the the fimbria (11%). Other extrauterine locations of implantation include the interstitial portion of the fallopian tube (2%-4%), ovary (3%), intra-abdominal (1.4%), cornua of a bicornuate or septate uterus (<1%), cervix (<1%), and along a prior Cesarean section scar (<1%). Heterotopic pregnancies are rare and occur when intrauterine and extrauterine pregnancies occur simultaneously.

Transabdominal and transvaginal ultrasound are typically performed in symptomatic patients. Evaluation of the uterus in an ectopic pregnancy would demonstrate absence of an intrauterine pregnancy with a beta HCG greater than 2000 IU. Instead, a complex extra-adnexal mass is typically seen. In a small percentage of cases, an intrauterine pseudogestational sac or decidual sac may be seen that lacks a typical decidual reaction seen in normal intrauterine pregnancies. A “ring of fire” sign is a nonspecific finding, and can be seen on Doppler ultrasound in tubal ectopic pregnancies and corpus luteal cysts.

Ectopic pregnancy treatment ranges from surgical intervention to more conservative management in select cases. Intramuscular methotrexate injections and expectant management with monitoring of serial beta HCG values and sonography can be used. The more invasive emergent laparotomy or laparoscopy is an option depending on the size of the ectopic, amount of free fluid, and presence of cardiac activity.

The patient was evaluated by the OB-GYN team and admitted for diagnostic laparoscopy, right salpingectomy, and dilatation and curettage. Patient tolerated the procedure well and was discharged home two days later.

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Suggested Reading:

1. Lin EP, Bhatt S, Dogra VS. Diagnostic Clues to Ectopic Pregnancy. Radiographics. 2008;28(6):1661.
2. Levine D.Ectopic Pregnancy. Radiology 2007; 245 (2): 385.
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