What's the Diagnosis? By Dr. Karen O'Brien

A 27 yo F presents to the ED with severe RLQ abdominal pain and vaginal bleeding. She is diaphoretic and appears uncomfortable. Her vital signs are: HR 60, BP 96/55, RR 20, spo2 100%. Her boyfriend states she had a positive pregnancy test at home. Bedside transabdominal US shows no IUP, but transvaginal reveals the following. What's the diagnosis? (scroll down for answer) 



Answer: Ectopic Pregnancy

  • 2% of all pregnancies; leading case of maternal death in 1st trimester
  • 96% occur in fallopian tubes
  • Usually presents with first trimester bleeding and/or abdominal pain
  • Don't forget about heterotopic pregnancy, especially in IVF!
  • hCG rises abnormally in these patients (<35% every two days in ectopics)
  • Evaluate for free fluid in pelvis as well to assess for rupture, as these patients can become hemodynamically unstable
  • Give Rhogam if patient is Rh negative
  • US shows a complex extraovarian adnexal mass in 89% cases; can also see a tubal ring (echogenic ring surrounding unruptured ectopic pregnancy- 95% PPV for ectopic)
  • Unstable patient--> immediate GYN consult
  • If hCG is above discriminatory zone (~3,500), TVUS does not show IUP and you still have high clinical suspicion for ectopic --> consult GYN
  • If patient is hemodynamically stable, and TVUS is nondiagnostic see flowchart below for management (source: UptoDate)





Alkatout I, Honemeyer U, Strauss A, Tinelli A, Malvasi A, Jonat W, et al. Clinical diagnosis and treatment of ectopic pregnancy. Obstet Gynecol Surv. 2013; 68:571-581. 


Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004 Jul;104(1):50-5. 


Atri M, Leduc C, Gillett P, Bret PM, Reinhold C, Kintzen G, Aldis AE, Thibodeau M. Role of endovaginal sonography in the diagnosis and management of ectopic pregnancy. Radiographics. 1996 Jul;16(4):755-74


Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol. 2013 Jan;121(1):65-70.