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)

https://www.uptodate.com/contents/image?imageKey=OBGYN%2F80606&topicKey=...

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