Presentation
Nulliparous presenting with lower abdominal pains three days per vaginal bleeding. PDT positive. To rule out ectopic pregnancy.
Patient Data
A trans-abdominal targeted intra-abdominal-pelvic sonographic evaluation yields a thick-walled, echogenic, and internally irregularly outlined fluid-filled structure within the right adnexal region/ipsilateral infero-medial right para-ovarian aspect. A conspicuous echogenic acardiac focus (intrinsically sighted within the structure above) corresponds to 7 weeks gestation by crown-rump length. Moderate low-level echo-filled free fluid is noted within the Douglas pouch and extending into the right upper abdominal quadrant consistent with hemorrhage/hemoperitoneum. Both ovaries appeared bilaterally normal, with the right ovary exhibiting a normal-looking corpus luteum. The anteverted and non-gravid uterus showed smooth outer contours with no focal myometrial/endometrial lesions.
Case Discussion
In the setting of a positive pregnancy test, amenorrhea, and a clinical question to exclude ectopic pregnancy, urgent and targeted abdominal-pelvic ultrasound imaging comes in handy as part of the clinical management. The sonographic features unequivocally pointed towards a leaking right-sided extra-uterine ectopic pregnancy in this scenario. The subsequent quantitative laboratory serum beta HCG titer level of 4731 mIU/mL further strengthened the diagnosis. However, the ectopic gestational sac demonstrated insignificant peripheral hyperfusion (atypical ring of fire; on color Doppler mapping). The acardiac intra-gestational sac focus suggested an embryonic demise at seven weeks gestation.
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