This patient's presentation of vaginal bleeding/spotting, lower abdominal pain, and adnexal tenderness is suspicious for an unruptured
ectopic pregnancy The majority of ectopic pregnancies occur in the fallopian tube. Most ectopic pregnancies are related to prior
infection with chlamydia and/or gonorrhea causing tubal damage, and these infections are often asymptomatic (subclinical pelvic
inflammatory disease) Other risk factors include prior tubal surgery, prior ectopic pregnancy, and in vitro fertilization.
The diagnosis of ectopic pregnancy is made by a pregnancy test combined with transvaginal ultrasound (TVUS) Ectopic
pregnancy is virtually ruled out if TVUS shows an intrauterine gestational sac in the setting of a positive �-hCG test Conversely,
ectopic pregnancy is confirmed if the gestational sac is seen at an ectopic site. TVUS is also useful in evaluating for rupture of the
tube or other structures, which presents as free fluid (blood) in the pelvic cul-de-sac and/or abdomen. Transabdominal ultrasound
cannot reliably visualize a gestational sac in early pregnancy.
(Choice A) Culdocentesis involves needle insertion into the posterior vaginal wall to see if there is blood in the peritoneal fluid from
the cul-de-sac (pouch of Douglas), which would suggest a ruptured ectopic pregnancy This is rarely performed today due to ease of
ultrasound.
(Choice B) Dilation and curettage (D&C) is surgical evacuation of the uterus for abortion (incomplete or missed). If the diagnosis of
ectopic pregnancy is unclear, D&C may confirm the presence or absence of chorionic tissue. D&C may also be performed if vaginal
ultrasound and blood work are inconclusive.
(Choice C) Endocervical nucleic acid amplification tests are indicated in cases of suspected genital tract infection (eg, cervicitis,
pelvic inflammatory disease). This patient has no cervical motion tenderness or discharge to suggest an active genital infection.
(Choices D and E) Laparoscopy is the gold standard treatment for a ruptured ectopic pregnancy which presents with the additional
symptoms of diffuse abdominal pain and eventually hemodynamic instability. Laparotomy may be considered for patients with acute
bleeding
Educational objective:
The triad of vaginal bleeding, lower abdominal pain, and adnexal tenderness is suspicious for an ectopic pregnancy. Diagnosis is
made by a positive pregnancy test and a transvaginal ultrasound showing a gestational sac at an ectopic site, most commonly the
fallopian tube.
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