Ultrasound of the Week #044
A 38 year old female presented to the ED around 21:00 after sudden onset of abdominal pain, diarrhea and vomiting around 13:30. She was triaged to the ?COVID area due to D&V. She was 4 weeks post implantation of an IVF embryo.
She reportedly had been feeling dizzy and had few fainting episodes with ambulance crew. She was pale with BP 77/44 and GCS 12/15. VBG at 21:30 showed a lactate of 6.4 and metabolic acidosis with PH 7.257, BE -8.
A rapid bedside ultrasound was performed showing the following:
This is a significant amount of intraperitoneal free fluid in RUQ and LUQ with floating loops of bowel seen. In the context of the history this is a ruptured ectopic pregnancy and the patient was rushed to theatre. Emergency laparoscopy confirmed left ectopic pregnancy within the fallopian tube, for which she went on to have salpingectomy.
– Whilst the ‘FAST scan’ is a scan focused on trauma, the skills are just as applicable to acutely unwell atraumatic patients in whom there may be concern for intraperitoneal free fluid such as possible ectopic pregnancy.
– The caudal liver edge (lowest point of the liver) is the most sensitive area for the detection of free fluid on bedside POCUS.
– Diarrhoea and vomiting continues to be a misleading presentation of ruptured Ectopic pregnancy.
– It is important to ‘eyeball’ patients if there are concerning clues in the ambulance handover and if patient looks unwell, to arrange for the patient to be seen immediately. This patient was extremely pale and had had syncope and hypotension with ambulance crew, all red flags that should prompt rapid senior assessment and management.
– IVF is associated with increased risk of tubal pregnancy.
- Lobo V, Hunter-Behrend M, Cullnan E, Higbee R, Phillips C, Williams S, Perera P, Gharahbaghian L. Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. West J Emerg Med. 2017 Feb;18(2):270-280. doi: 10.5811/westjem.2016.11.30435. Epub 2017 Jan 19. PMID: 28210364; PMCID: PMC5305137.
- Yoder, N., Tal, R. & Martin, J.R. Abdominal ectopic pregnancy after in vitro fertilization and single embryo transfer: a case report and systematic review. Reprod Biol Endocrinol14, 69 (2016). https://doi.org/10.1186/s12958-016-0201-x