CASE. Case HX 39 year old female 39 year old female From PCP for abdominal pain/ spotting From PCP for abdominal pain/ spotting Note from PCP Note from

CASECASE

Case HXCase HX

39 year old female 39 year old female From PCP for abdominal pain/ spottingFrom PCP for abdominal pain/ spotting Note from PCPNote from PCP

last 2 periods irregularlast 2 periods irregular Acute Abdomen Acute Abdomen Possible PIDPossible PID

G3P2012- ectopic 15 years agoG3P2012- ectopic 15 years ago Menses irregular x 6 moMenses irregular x 6 mo Denied sex x 2 yearsDenied sex x 2 years

Case HXCase HX

Pain- 6/10, Pain- 6/10, crampy crampy super pubicsuper pubic intermittent x 2 days intermittent x 2 days

Spotting x 6 days Spotting x 6 days No Urinary SxNo Urinary Sx No n/v/d/c No n/v/d/c No cp/sobNo cp/sob

Case PXCase PX T 97 HR 76 RR 16 BP 133/90 POx T 97 HR 76 RR 16 BP 133/90 POx

99%99% Well appearing*Well appearing* AbdomenAbdomen

softsoft mild midline super pubic tendernessmild midline super pubic tenderness Non distendedNon distended normal bowel soundsnormal bowel sounds

Pelvic examPelvic exam No CMTNo CMT os closedos closed min dark dischargemin dark discharge

Case LabsCase Labs

Positive U-Preg!Positive U-Preg! B-quant 17,953B-quant 17,953 T&S O+T&S O+ UA +UTIUA +UTI

UltrasoundUltrasound












U/S FindingsU/S Findings

IUPIUP Minimal FFMinimal FF Lt ovary Lt ovary

Heterogeneous massHeterogeneous mass Double desidual signDouble desidual sign Ectopic pregnancy left ovaryEctopic pregnancy left ovary

+ Prior ectopic. + Prior ectopic.

No tubal ligation or IVFNo tubal ligation or IVF

Encounter conclusionEncounter conclusion Diagnosis Diagnosis

Threatened AB, Corpus Luteal cyst Threatened AB, Corpus Luteal cyst UTI UTI

RX: Macrobid & PNVRX: Macrobid & PNV Pt was RH + Pt was RH +

No need for Rhogam No need for Rhogam Discharged home with good d/c Discharged home with good d/c

instructions including need for f/u pelvic instructions including need for f/u pelvic u/s and prompt OB f/u, because of ovarian u/s and prompt OB f/u, because of ovarian abnormalityabnormality

Attending spoke to OBAttending spoke to OB

22ndnd visit visit

3 days later3 days later 97.3 74 18 121/73 100%97.3 74 18 121/73 100% Pt still w/ abd cramping, more bleeding, Pt still w/ abd cramping, more bleeding,

and vomitingand vomiting Scheduled for ADC that dayScheduled for ADC that day ADC showed IUP- and presumed cystic ADC showed IUP- and presumed cystic

mass in ovary w/ copious FF mass in ovary w/ copious FF Went to OR for Ex laparoscopy – Went to OR for Ex laparoscopy –

diagnosis of ruptured ectopic -diagnosis of ruptured ectopic -Heterotopic PregnancyHeterotopic Pregnancy

OutcomeOutcome

Vitals remained stableVitals remained stable Hemoglobin remained stableHemoglobin remained stable Pt did well.Pt did well.

Heterotopic Heterotopic PregnancyPregnancy

Alexis Palley Langsfeld MDAlexis Palley Langsfeld MD

IntroductionIntroduction

Case reportCase report DefinitionDefinition IncidenceIncidence ED work upED work up Differential DiagnosisDifferential Diagnosis What can I do not to miss this?What can I do not to miss this? ConclusionConclusion

Heterotopic Heterotopic PregnancyPregnancyDefinitionDefinition

Co-existent Co-existent gestations that gestations that

occur at 2 or more occur at 2 or more implantation sites.implantation sites.

HeterotopicHeterotopic

Case study of a 39 year old Case study of a 39 year old Women undergoing IVFWomen undergoing IVF

Brigham RAD. Brigham RAD. Michael Cooney MD, Mary C Frates Michael Cooney MD, Mary C Frates

MD, Peter M Doubilet MD PhD MD, Peter M Doubilet MD PhD

Heterotopic pregnancyHeterotopic pregnancy

Heterotopic CRLHeterotopic CRL

Heterotopic FHRHeterotopic FHR

Heterotopic FHRHeterotopic FHR

IUP after treatment of IUP after treatment of ectopic w/ KCLectopic w/ KCL

Heterotopic pregnancyHeterotopic pregnancyEpidemiologyEpidemiology

Incidence 1: 30,000 - 1: 100 Incidence 1: 30,000 - 1: 100 As high as 1:100 With fertility As high as 1:100 With fertility

treatment ovulation inducers, or IVF. treatment ovulation inducers, or IVF. Tal et. al. Tal et. al.

Risk FactorsRisk Factors IVFIVF Hormonal fertility treatmentsHormonal fertility treatments Tubal ligationTubal ligation Prior ectopic/anatomic Prior ectopic/anatomic

abnormalities/PID/Endometriosisabnormalities/PID/Endometriosis

Heterotopic ED Work UpHeterotopic ED Work Up Women of child bearing age w/ belly pain or UG Women of child bearing age w/ belly pain or UG

complaintcomplaint UA/U-PREGUA/U-PREG

VITALS are vital!VITALS are vital! Blood work?Blood work?

If bleeding check T&SIf bleeding check T&S B-QuantB-Quant HgbHgb

Fluids-clinical judgmentFluids-clinical judgment PelvicPelvic

CxCx Wet mountWet mount

UltrasoundUltrasound OB consult / definitive treatmentOB consult / definitive treatment

Heterotopic Ultrasound Heterotopic Ultrasound FindingsFindings

IUPIUP Thick walled, fluid filled structureThick walled, fluid filled structure May show dd signMay show dd sign May have fetus or clot within it May have fetus or clot within it Can be anywhereCan be anywhere

In ovaryIn ovary In tubeIn tube In adenexaIn adenexa Adjacent to any structureAdjacent to any structure

HeterotopicHeterotopictreatment/outcomestreatment/outcomes

Surgical removalSurgical removal OophorectomyOophorectomy SalpingectomySalpingectomy HysterectomyHysterectomy

MethotrexateMethotrexate Embolization if necessary for Embolization if necessary for

hemorrhagehemorrhage Kcl injection into ectopic embryo Kcl injection into ectopic embryo

under u/s guidance under u/s guidance

Differential DiagnosisDifferential Diagnosis

Ectopic PregnancyEctopic Pregnancy Follicular cyst- 1Follicular cyst- 1stst half cycle half cycle Corpus Luteal CystCorpus Luteal Cyst IUPIUP AppendicitisAppendicitis UTIUTI PID PID

Ectopic PregnancyEctopic Pregnancy

13% of first trimester pregnancies 13% of first trimester pregnancies presenting to the ED with Pain presenting to the ED with Pain and/or vaginal bleeding have an and/or vaginal bleeding have an ectopic pregnancy.ectopic pregnancy.

Ectopic Pregnancy: Prospective Ectopic Pregnancy: Prospective Study With Improved Diagnostic Study With Improved Diagnostic AccuracyAccuracy

BC Kaplan, BC Kaplan, Ann Emerg MedAnn Emerg Med 1996;28:10-171996;28:10-17


2% of all pregnancies2% of all pregnancies 6 fold inc since 19706 fold inc since 1970

9% of pregnancy related deaths9% of pregnancy related deaths Risk FactorsRisk Factors

PIDPID Prior ectopicPrior ectopic Tubal LigationTubal Ligation EndometriosisEndometriosis Infertility treatmentsInfertility treatments Anatomic abnormalitiesAnatomic abnormalities SMOKINGSMOKING

Only 3% are ovarian. Bouyer, JOnly 3% are ovarian. Bouyer, J


Corpus Luteal Cyst Corpus Luteal Cyst Functional CystFunctional Cyst After ovulation, the ruptured follicle After ovulation, the ruptured follicle

develops into the corpus luteumdevelops into the corpus luteum Corpus luteum makes progesterone in Corpus luteum makes progesterone in

anticipation for supporting a fertilized egganticipation for supporting a fertilized egg With no fertilization, the CL withers, With no fertilization, the CL withers,

progesterone falls, and menses occurprogesterone falls, and menses occur A corpus luteal cyst develops when the CL A corpus luteal cyst develops when the CL

does not whither, and instead fills w/ fluiddoes not whither, and instead fills w/ fluid

Corpus Leutial Cyst U/S Corpus Leutial Cyst U/S

In the ovaryIn the ovary Thin WalledThin Walled

often irregularoften irregular Large Large Fluid filledFluid filled Should not show dd signShould not show dd sign No yolk sac!- but may have clot or No yolk sac!- but may have clot or

septumseptum

Corpus Luteal CystCorpus Luteal Cyst

How Do I Not Miss My How Do I Not Miss My Heterotopic Heterotopic

Evaluate for risk factorsEvaluate for risk factors Clinical pictureClinical picture

Is your pt stableIs your pt stable HRHR BPBP

Check a u-preg in all women of reproductive age with Check a u-preg in all women of reproductive age with belly pain or u/g complaintsbelly pain or u/g complaints

LOOK with the ultrasoundLOOK with the ultrasound View the adenexaView the adenexa Look for free fluidLook for free fluid

B-Quant may be helpfulB-Quant may be helpful If you are not comfortable w/ your scan – get helpIf you are not comfortable w/ your scan – get help Keep looking for itKeep looking for it Good discharge instructionsGood discharge instructions

ConclusionConclusion

Heterotopic pregnancies are more Heterotopic pregnancies are more common than they once werecommon than they once were

Pt with risk factors need to be taken Pt with risk factors need to be taken seriouslyseriously

Check the adenexaCheck the adenexa Review your differentialReview your differential Give good discharge instructionsGive good discharge instructions If you are not comfortable w/ your scan If you are not comfortable w/ your scan

– get help!– get help!

Documents

CASE. Case HX 39 year old female 39 year old female From PCP for abdominal pain/ spotting From PCP for abdominal pain/ spotting Note from PCP Note from