Senior Report 5.12

Case Presentation by Dr. Bao Dang

CC: “I think I’m having a miscarriage”

HPI: A 23-year-old G3P1011 patient states that she took a home pregnancy test two weeks ago that was positive.  Her last menstrual period was about 8 weeks ago.  She has been having vaginal bleeding for 7 days.  The bleeding started getting heavier over the last 3 days.  Today she noticed that there were large clots.  She’s had a similar presentation with her previous abortion and thinks that she may be having another one.  She complains of abdominal pain that is crampy and located in the suprapubic region without radiation, exacerbating or relieving factors.  Pt has not yet seen a physician for her pregnancy or vaginal bleeding.  No fevers, chills, nausea, vomiting, dysuria, or diarrhea.

PAST MEDICAL HISTORY:  asthma.

PAST SURGICAL HISTORY:  Cesarean section.

MEDICATIONS:  albuterol metered dose inhaler.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  Positive for tobacco smoking; denies alcohol or illicit drug use.

SEXUAL HISTORY:  Positive PID years ago, no IUD use, no use of infertility treatment.  LMP 8 weeks ago

PE:

VITAL SIGNS:  BP131/78, HR 117, RR16, T36.2, P Ox 99% RA.

CONSTITUTIONAL:  The patient is awake, alert, and oriented x3, able to talk in full sentences and is comprehensible. Pt appears comfortable on her stretcher.

HEENT:  Conjunctivae are pink.  Mouth/throat – oral mucosa is moist.

PULMONARY:  Lung sounds are clear bilaterally.  No wheezes, rales, or rhonchi.

CARDIOVASCULAR:  S1 and S2 are present.  Tachycardic rate and regular rhythm.  No murmurs, rubs, or gallops.

GASTROINTESTINAL:  Normal bowel sounds. Abdomen is soft.  There is tenderness to palpation at the suprapubic area; however, no guarding or rebound tenderness.

GENITOURINARY:  Blood is seen within vaginal vault without clots.  The cervical os was closed.  No cervical motion tenderness.  Uterus midline, anteverted, normal size and shape, mobile, no masses, and non-tender.  No adnexal mass or tenderness.

Laboratory Studies:

β-HCG quantitative: 150

CBC: WBC 6.9, Hgb 12.5, Hct 37.0, Plts 370

UA: Nitrite & LE negative, Blood 3 +, RBC 10-20/HPF, WBC <5/HPF

Ultrasound:

Questions:

1. Which of the following poses the highest risk for ectopic pregnancy?

A.            history of previous pelvic inflammatory disease

B.            infertility treatment

C.            intrauterine device use

D.            previous ectopic pregnancy

E.            tubal ligation

2.  Which of the following conditions is most likely if the β-HCG level fails to double, or decreases in 48-hours?

A.            ectopic pregnancy

B.            heterotopic pregnancy

C.            non-viable intrauterine pregnancy

D.            viable intrauterine pregnancy

3.  Which of the following is associated with methotrexate use?

A.            an increase in abdominal pain is observed in about 30-60% of patients treated with methotrexate

B.            delayed tubal rupture occur in about 3-20%

C.            nausea, vomiting & diarrhea in about 5-20% of patients

D.            patient should be instructed to avoid vitamins containing folic acid and avoid sexual intercourse until β-HCG level has come back to baseline

E.            all of the above

Answers:
1. E.
Female patients of reproductive age who present with amenorrhea, abdominal pain and/or vaginal bleeding must have ectopic pregnancy in the differential. Ectopic pregnancy is defined as implantation of a fertilized ovum in any location other than the endometrial cavity. Up to 2% of reported pregnancies are ectopic. 95% of ectopic pregnancies implant in a fallopian tube, of which 80% implant in the ampulla, 12% in the isthmus, 5% in the fimbrae, and 2% at the junction of the uterus and fallopian tube. Other rare sites of implantation include abdominal cavity, ovary, and cervix.
All the above question responses increase the risk of ectopic pregnancy. A history of tubal ligation, however, poses the highest risk. About 10% of ectopic pregnancies occur in women with prior tubal ligation. Unless there is a confirmed hysterectomy, pregnancy cannot be excluded in a child-bearing-aged female.
2. A.
There is no combination of historical and physical findings that will definitively diagnose ectopic pregnancy. The diagnosis is made clinically by combining elements of the history and physical exam with ultrasound findings and a quantitative β-HCG. Urine β-HCG will screen for pregnancy. The quantitative β-HCG is used to guide the disposition of the patient. Trans-vaginal ultrasound (TVUS) should reliably detect an intrauterine pregnancy (IUP) if β-HCG level is above 1500-2000 mIU/mL. This level is called the discriminatory zone. Trans-abdominal ultrasound should be able to detect an IUP when β-HCG is above 6,500 mIU/mL. For patients with β-HCG above the discriminatory level and a TVUS demonstrating an IUP, ectopic can be reliably ruled out. Patients with β-HCG below the discriminatory zone should be instructed to follow-up in two days for a repeat quantitative level. The β-HCG should approximately double in 48 hours in a normal gestation. A TVUS should be obtained once the β-HCG level is above discriminatory zone.

3. E.
Ectopic pregnancy can be managed via pharmacological or surgical methods. Methotrexate is the primary agent used in pharmacological management. It is an analog of folic acid that will be taken up by rapidly dividing cells, such as those of the fetus, and disrupts DNA and RNA synthesis within those cells. The use of methotrexate for treatment should only be used in patients who meet the following criteria: patient would like to avoid surgery, have ultrasound findings that show no fluid outside the pelvis and adnexal mass less than 4.0 cm, available for weekly follow-up visits, and is hemodynamically stable. The surgical approach to treatment involves either a complete salpingectomy or tubal preserving strategy. A consultation with OB/Gyn is always needed.

Case Summary:
The patient’s ultrasound showed evidence concerning for a ruptured ectopic pregnancy. However, clinically the patient was stable. She did not show any signs of shock or instability often associated with ruptured ectopic pregnancy. OB/Gyn was consulted, and the patient was taken to the OR for emergent laparoscopic surgery. At surgery, a large amount of adhesions were demonstrated, but no evidence of an ectopic pregnancy. Adhesions were lysed and she was discharged home on post-operative day #1. Biopsy of the right adnexa showed no evidence of ectopic pregnancy. Adhesions were likely from previous PID. The patient likely had a spontaneous abortion of her pregnancy.

2 Responses

  1. 1.
    2.
    3.

    I’m coming for the # 1 Spot

    John

  2. From Dr. Leo Bunting

    Thanks Dr. Dang for an excellent case. I just want to clarify one thing:

    If the quant is 1200 and the ultrasound is non-diagnostic, you should not as a rule discharge patients for followup quants in 48hours. There have been ruptured ectopics described with quants less than 10 (for example http://www.ncbi.nlm.nih.gov/m/pubmed/17694977/). I’ve seen them personally with quants in the 300-500 range. It is often common to not see the ectopic on even TVUS and possible to miss small ruptures. Therefore we have to maintain a high index of suspicion even if the quant is below the discriminatory zone.

    So if the quant is below 1500, nothing concerning on TVUS (no large free fluid, no “complex mass not fully characterized”) and a benign exam = call an OB to establish followup and continuity of care for repeat beta.

    If there is something concerning about the patient, I consult OB.

    Also, forget the discriminatory zone for trans abdominal scanning – it varies dramatically from hospital to hospital.

    Thanks, Leo

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