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CASE

CASE. Case HX. 39 year old female From PCP for abdominal pain/ spotting Note from PCP last 2 periods irregular Acute Abdomen Possible PID G3P2012- ectopic 15 years ago Menses irregular x 6 mo Denied sex x 2 years. Case HX. Pain- 6/10, crampy super pubic

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CASE

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  1. CASE

  2. Case HX • 39 year old female • From PCP for abdominal pain/ spotting • Note from PCP • last 2 periods irregular • Acute Abdomen • Possible PID • G3P2012- ectopic 15 years ago • Menses irregular x 6 mo • Denied sex x 2 years

  3. Case HX • Pain- 6/10, • crampy • super pubic • intermittent x 2 days • Spotting x 6 days • No Urinary Sx • No n/v/d/c • No cp/sob

  4. Case PX • T 97 HR 76 RR 16 BP 133/90 POx 99% • Well appearing* • Abdomen • soft • mild midline super pubic tenderness • Non distended • normal bowel sounds • Pelvic exam • No CMT • os closed • min dark discharge

  5. Case Labs • Positive U-Preg! • B-quant 17,953 • T&S O+ • UA +UTI

  6. Ultrasound

  7. Ultrasound

  8. Ultrasound

  9. Ultrasound

  10. Ultrasound

  11. Ultrasound

  12. Ultrasound

  13. Ultrasound

  14. Ultrasound

  15. Ultrasound

  16. Ultrasound

  17. Ultrasound

  18. U/S Findings • IUP • Minimal FF • Lt ovary • Heterogeneous mass • Double desidual sign • Ectopic pregnancy left ovary + Prior ectopic. No tubal ligation or IVF

  19. Encounter conclusion • Diagnosis • Threatened AB, Corpus Luteal cyst • UTI • RX: Macrobid & PNV • Pt was RH + • No need for Rhogam • Discharged home with good d/c instructions including need for f/u pelvic u/s and prompt OB f/u, because of ovarian abnormality • Attending spoke to OB

  20. 2nd visit • 3 days later • 97.3 74 18 121/73 100% • Pt still w/ abd cramping, more bleeding, and vomiting • Scheduled for ADC that day • ADC showed IUP- and presumed cystic mass in ovary w/ copious FF • Went to OR for Ex laparoscopy – diagnosis of ruptured ectopic -Heterotopic Pregnancy

  21. Outcome • Vitals remained stable • Hemoglobin remained stable • Pt did well.

  22. Heterotopic Pregnancy Alexis Palley Langsfeld MD

  23. Introduction • Case report • Definition • Incidence • ED work up • Differential Diagnosis • What can I do not to miss this? • Conclusion

  24. Heterotopic PregnancyDefinition Co-existent gestations that occur at 2 or more implantation sites.

  25. Heterotopic • Case study of a 39 year old Women undergoing IVF • Brigham RAD. • Michael Cooney MD, Mary C Frates MD, Peter M Doubilet MD PhD

  26. Heterotopic pregnancy

  27. Heterotopic CRL

  28. Heterotopic FHR

  29. Heterotopic FHR

  30. IUP after treatment of ectopic w/ KCL

  31. Heterotopic pregnancyEpidemiology • Incidence 1: 30,000 - 1: 100 • As high as 1:100 With fertility treatment ovulation inducers, or IVF. Tal et. al. • Risk Factors • IVF • Hormonal fertility treatments • Tubal ligation • Prior ectopic/anatomic abnormalities/PID/Endometriosis

  32. Heterotopic ED Work Up • Women of child bearing age w/ belly pain or UG complaint • UA/U-PREG • VITALS are vital! • Blood work? • If bleeding check T&S • B-Quant • Hgb • Fluids-clinical judgment • Pelvic • Cx • Wet mount • Ultrasound • OB consult / definitive treatment

  33. Heterotopic Ultrasound Findings • IUP • Thick walled, fluid filled structure • May show dd sign • May have fetus or clot within it • Can be anywhere • In ovary • In tube • In adenexa • Adjacent to any structure

  34. Heterotopictreatment/outcomes • Surgical removal • Oophorectomy • Salpingectomy • Hysterectomy • Methotrexate • Embolization if necessary for hemorrhage • Kcl injection into ectopic embryo under u/s guidance

  35. Differential Diagnosis • Ectopic Pregnancy • Follicular cyst- 1st half cycle • Corpus Luteal Cyst • IUP • Appendicitis • UTI • PID

  36. Ectopic Pregnancy • 13% of first trimester pregnancies presenting to the ED with Pain and/or vaginal bleeding have an ectopic pregnancy. • Ectopic Pregnancy: Prospective Study With Improved Diagnostic Accuracy BC Kaplan, Ann Emerg Med 1996;28:10-17

  37. Ectopic Pregnancy • 2% of all pregnancies • 6 fold inc since 1970 • 9% of pregnancy related deaths • Risk Factors • PID • Prior ectopic • Tubal Ligation • Endometriosis • Infertility treatments • Anatomic abnormalities • SMOKING • Only 3% are ovarian. Bouyer, J

  38. Ectopic Pregnancy

  39. Corpus Luteal Cyst • Functional Cyst • After ovulation, the ruptured follicle develops into the corpus luteum • Corpus luteum makes progesterone in anticipation for supporting a fertilized egg • With no fertilization, the CL withers, progesterone falls, and menses occur • A corpus luteal cyst develops when the CL does not whither, and instead fills w/ fluid

  40. Corpus Leutial Cyst U/S • In the ovary • Thin Walled • often irregular • Large • Fluid filled • Should not show dd sign • No yolk sac!- but may have clot or septum

  41. Corpus Luteal Cyst

  42. How Do I Not Miss My Heterotopic • Evaluate for risk factors • Clinical picture • Is your pt stable • HR • BP • Check a u-preg in all women of reproductive age with belly pain or u/g complaints • LOOK with the ultrasound • View the adenexa • Look for free fluid • B-Quant may be helpful • If you are not comfortable w/ your scan – get help • Keep looking for it • Good discharge instructions

  43. Conclusion • Heterotopic pregnancies are more common than they once were • Pt with risk factors need to be taken seriously • Check the adenexa • Review your differential • Give good discharge instructions • If you are not comfortable w/ your scan – get help!

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