Images in Emergency Medicine
Article Outline
A 19-year-old primigravid woman at 8 weeks 4 days’ gestation by her last menstrual period presented to the emergency department (ED), complaining of a 2-week history of abdominal pain. She described it as a sharp, 7/10 cramping pain located in the suprapubic region of her lower abdomen. The pain was constant, nonradiating, and not alleviated or aggravated by any means. The patient denied any fever, chills, nausea, vomiting, or diarrhea. She had not experienced any dysuria or change in her bowel habits. On examination, her vital signs were within normal limits, and she was in no distress. Palpation of her abdomen revealed midline suprapubic tenderness, without guarding or peritoneal signs. The rest of her examination results were unremarkable. The patient had a pelvic ultrasonography performed (Figure 1, Figure 2).
Figure 1.
Sagittal view of the uterus, using an endovaginal probe.
Figure 2.
Split view of the right and left adnexa in the coronal plane. Used with permission of Thomas G. Costantino, MD, Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA.
Diagnosis
Bilateral tubal ectopic pregnancies
The patient was found to have bilateral tubal ectopic pregnancies on ultrasonography, each with documented cardiac activity. Figure 1 demonstrates a uterus with no signs of intrauterine pregnancy (such as a gestational sac containing a yolk sac or fetal pole). The diagnosis of ectopic pregnancy was confirmed by visualizing a fetal pole with cardiac activity (not shown) in each adnexa (Figure 2). She was immediately taken to the operating room, where bilateral salpingostomies and a right distal partial salpingectomy were performed. The incidence of ectopic pregnancy is 11.4 in 1000 pregnancies in the United States.1 The incidence of heterotopic pregnancy is about 1 in 4000.2 Spontaneous bilateral tubal ectopic pregnancies are thought to occur at a rate of 1:125,000.3 In symptomatic first-trimester patients presenting to the ED, about 5% will have an ectopic pregnancy, with less than half of these diagnosed by ultrasonography on the initial visit.4 Although twin ectopic pregnancy is rare, early diagnosis of any ectopic pregnancy is key to treatment. Clinicians need to have a high index of suspicion for ectopic pregnancy in patients who present to the ED with a symptomatic first-trimester pregnancy.
References
- . Ectopic pregnancy: United States, 1990-1992. MMWR Morb Mortal Wkly Rep. 1995;44:46–48
- Combined pregnancy: the Mount Sinai experience. Obstet Gynecol Surv. 1986;41:603–613
- . Bilateral simultaneous extrauterine pregnancy. Am J Obstet Gynecol. 1948;56:1198–1200
- . Outcome of patients with an indeterminate emergency department first trimester pelvic ultrasound to rule out ectopic pregnancy. Acad Emerg Med. 2004;11:912–917
PII: S0196-0644(07)00678-6
doi:10.1016/j.annemergmed.2007.06.002
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
