CASE

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CASE
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Case HX

• 39 year old female
• From PCP for abdominal pain/ spotting
• Note from PCP
• last 2 periods irregular
• Acute Abdomen
• Possible PID
• G3P2012- ectopic 15 years ago
• Menses irregular x 6 mo
• Denied sex x 2 years

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Case HX

• Pain- 6/10,
• crampy
• super pubic
• intermittent x 2 days
• Spotting x 6 days
• No Urinary Sx
• No n/v/d/c
• No cp/sob

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Case PX

• T 97 HR 76 RR 16 BP 133/90 POx 99
• Well appearing
• Abdomen
• soft
• mild midline super pubic tenderness
• Non distended
• normal bowel sounds
• Pelvic exam
• No CMT
• os closed
• min dark discharge

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Case Labs

• Positive U-Preg!
• B-quant 17,953
• TS O
• UA UTI

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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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Ultrasound
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U/S Findings

• IUP
• Minimal FF
• Lt ovary
• Heterogeneous mass
• Double desidual sign
• Ectopic pregnancy left ovary
• Prior ectopic.
• No tubal ligation or IVF

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Encounter conclusion

• Diagnosis
• Threatened AB, Corpus Luteal cyst
• UTI
• RX Macrobid PNV
• Pt was RH
• No need for Rhogam
• Discharged home with good d/c instructions
  including need for f/u pelvic u/s and prompt OB
  f/u, because of ovarian abnormality
• Attending spoke to OB

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2nd visit

• 3 days later
• 97.3 74 18 121/73 100
• Pt still w/ abd cramping, more bleeding, and
  vomiting
• Scheduled for ADC that day
• ADC showed IUP- and presumed cystic mass in ovary
  w/ copious FF
• Went to OR for Ex laparoscopy diagnosis of
  ruptured ectopic -Heterotopic Pregnancy

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Outcome

• Vitals remained stable
• Hemoglobin remained stable
• Pt did well.

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Heterotopic Pregnancy

• Alexis Palley Langsfeld MD

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Introduction

• Case report
• Definition
• Incidence
• ED work up
• Differential Diagnosis
• What can I do not to miss this?
• Conclusion

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Heterotopic PregnancyDefinition Co-existent
gestations that occur at 2 or more implantation
sites.
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Heterotopic

• Case study of a 39 year old Women undergoing IVF
• Brigham RAD.
• Michael Cooney MD, Mary C Frates MD, Peter M
  Doubilet MD PhD

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Heterotopic pregnancy
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Heterotopic CRL
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Heterotopic FHR
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Heterotopic FHR
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IUP after treatment of ectopic w/ KCL
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Heterotopic pregnancyEpidemiology

• Incidence 1 30,000 - 1 100
• As high as 1100 With fertility treatment
  ovulation inducers, or IVF. Tal et. al.
• Risk Factors
• IVF
• Hormonal fertility treatments
• Tubal ligation
• Prior ectopic/anatomic abnormalities/PID/Endometri
  osis

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Heterotopic ED Work Up

• Women of child bearing age w/ belly pain or UG
  complaint
• UA/U-PREG
• VITALS are vital!
• Blood work?
• If bleeding check TS
• B-Quant
• Hgb
• Fluids-clinical judgment
• Pelvic
• Cx
• Wet mount
• Ultrasound
• OB consult / definitive treatment

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Heterotopic Ultrasound Findings

• IUP
• Thick walled, fluid filled structure
• May show dd sign
• May have fetus or clot within it
• Can be anywhere
• In ovary
• In tube
• In adenexa
• Adjacent to any structure

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Heterotopictreatment/outcomes

• Surgical removal
• Oophorectomy
• Salpingectomy
• Hysterectomy
• Methotrexate
• Embolization if necessary for hemorrhage
• Kcl injection into ectopic embryo under u/s
  guidance

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Differential Diagnosis

• Ectopic Pregnancy
• Follicular cyst- 1st half cycle
• Corpus Luteal Cyst
• IUP
• Appendicitis
• UTI
• PID

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Ectopic Pregnancy

• 13 of first trimester pregnancies presenting to
  the ED with Pain and/or vaginal bleeding have an
  ectopic pregnancy.
• Ectopic Pregnancy Prospective Study With
  Improved Diagnostic Accuracy
• BC Kaplan, Ann Emerg Med 19962810-17

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Ectopic Pregnancy

• 2 of all pregnancies
• 6 fold inc since 1970
• 9 of pregnancy related deaths
• Risk Factors
• PID
• Prior ectopic
• Tubal Ligation
• Endometriosis
• Infertility treatments
• Anatomic abnormalities
• SMOKING
• Only 3 are ovarian. Bouyer, J

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Ectopic Pregnancy
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Corpus Luteal Cyst

• Functional Cyst
• After ovulation, the ruptured follicle develops
  into the corpus luteum
• Corpus luteum makes progesterone in anticipation
  for supporting a fertilized egg
• With no fertilization, the CL withers,
  progesterone falls, and menses occur
• A corpus luteal cyst develops when the CL does
  not whither, and instead fills w/ fluid

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Corpus Leutial Cyst U/S

• In the ovary
• Thin Walled
• often irregular
• Large
• Fluid filled
• Should not show dd sign
• No yolk sac!- but may have clot or septum

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Corpus Luteal Cyst
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How Do I Not Miss My Heterotopic

• Evaluate for risk factors
• Clinical picture
• Is your pt stable
• HR
• BP
• Check a u-preg in all women of reproductive age
  with belly pain or u/g complaints
• LOOK with the ultrasound
• View the adenexa
• Look for free fluid
• B-Quant may be helpful
• If you are not comfortable w/ your scan get
  help
• Keep looking for it
• Good discharge instructions

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Conclusion

• Heterotopic pregnancies are more common than they
  once were
• Pt with risk factors need to be taken seriously
• Check the adenexa
• Review your differential
• Give good discharge instructions
• If you are not comfortable w/ your scan get
  help!