A 23YearOld Female with Abdominal Pain

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A 23-Year-Old Female with Abdominal Pain
Eugene G. Martin, Ph.D. Associate Professor of
Pathology Laboratory Medicine

• A Powerpoint companion to
• A UMDNJ-Robert Wood Johnson Medical School
  Printed Case
• Female Reproductive Systems Case Study 1
  UMDNJ-Robert Wood Johnson Medical
  SchoolPiscataway, NJ

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Clinical Summary

• 23 year old white female male presented to the
  emergency room
• Chief Complaint (CC) Pain Abdominal left lower
  quadrant (LLQ) radiating to groin
• Two menstrual periods missed. Past history of
  pelvic inflammatory disease (PID)
• Urine Pregnancy test POSITIVE.
• Bed rest advised
• Because pain persisted and frequent spotting she
  was seen by an obstetrician
• Obstetrical assessment
• Uterus appropriate size for dates
• Transabdominal ultrasound NOT ORDERED
• Bed rest advised
• Pain persisted 4 days later brought to the ER
  by ambulance
• Emergency Room assessment
• Appearance Patient appeared tired, slightly
  confused, and sweaty
• Physical Exam
• Temp. 99.5 oF
• HR 110 bpm - thready
• BP 60/40
• Respirations 23
• Lungs clear to ascultation and percussion

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Significance of Patient History

• What is the differential diagnosis

• What is the significance of
• Prior Pelvic Inflammatory Disease (PID)?
• Not performing a transabdominal ultrasound?
• Low-grade fever?
• Board-like abdominal rigidity?
• What is rebound tenderness?
• Why does she demonstrate confusion?

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HEMATOLOGY
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CHEMISTRY
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What Do You See?

• Endometrial currettings (HE x40)
• Arias-Stella reaction
• Decidualized stroma

• Material from left fallopian tube
• Chorionic villi demonstrating
• Syncytiotrophoblast
• Inner cytotrophoblast

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Neoplastic MimicsArias Stella Reaction
Atypical glandular cells singly and in groups
with abundant cytoplasm and markedly enlarged
vesicular nuclei with prominent nucleoli.
Benign mimics of endocervical neoplasia include
marked reactive changes/repair, brush artifact,
endometrial cells and Arias-Stella reaction
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Pelvic Inflammatory Disease

• Pelvic inflammatory disease is usually caused by
  invasion of either gonorrhea or chlamydia from
  the cervix up to the uterus and tubes.
• The infection causes an intense inflammatory
  response. Bacteria and neutrophils fill the tubes
  as the body combats the infection.
• Eventually, the body wins and the bacteria are
  controlled and destroyed. However, during the
  healing process the delicate inner lining of the
  tubes (tubal mucosa) is permanently scarred..

• The end of the tube by the ovaries may become
  partially or completely blocked, and scar tissue
  often forms on the outside of the tubes and
  ovaries.
• All of these factors can impact ovarian or tubal
  function and the chances for conception in the
  future. If pelvic inflammatory disease is treated
  very early and aggressively with IV antibiotics,
  the tubal damage might be minimized, and
  fertility maintained

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Pelvic Inflammatory disease

• Etiologic agents
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma hominis
• Bacteroides sp.
• Escherichia coli
• Staphloccus aureus
• Streptococcal sp.
• Mycobacterium infection
• Actinomycosis
• Schistosomiasis

• Complications
• Chronic salpingitis
• Peritonitis
• Intestinal obstruction due to adhesions
• Septicemia
• Infertility
• Ectopic Pregnancy

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Over the counter pregnancy kits

• Most home kits dye-based qualitative sandwich
  urine immunoassay
• Maufacturers - Claim 90 accuracy, but urine HCG
  can vary due to changes in specific gravity.
• Studies have shown a 40 false negative rate due
  to a failure to properly follow kit instructions

• Clinical labs use quantitative or
  semi-quantitative assays.
• Serum shows better analytic sensitivity
• Limitations
• Prozoning Very high HCG ? false neg
• Blood in urine ? false neg or pos
• Proteinuria ? false pos.
• Methadone ? false pos.
• Low levels of HCG in non-pregnant women ? false
  pos.)

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Ultrasound Image of ectopic pregnancy

• Uterus outlined in red
• Uterus lining marked in green
• Fluid in uterus at blue circle is sometimes
  referred to as a pseudosac
• The ectopic pregnancy is noted in yellow

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Transabdominal Ultrasound in Detection of Ectopic
Pregnancies

• Detection of ectopic pregnancies
• In approximately 2/3 of patients with ectopic
  pregnancies hCG levels DO NOT rise at the
  predicted rate for normal intrauterine pregnancy
• In 1/3 of patients, the hCG levels do rise at the
  predicted rate. Ultrasound is essential to make
  the diagnosis.
• The usual finding for ectopic is a mass on one
  side, some fluid in the pelvis, and no normal
  pregnancy structures in the uterus.
• Conclusive diagnosis of ectopic by ultrasound can
  only be made if fetus or fetal cardiac motion is
  seen outside the uterus. This is only seen in
  about 20 of ectopics.

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Hormones and Ectopic Pregnancies

• Progesterone Levels and Ectopic Pregnancies
• Progesterone levels are usually not of much use
  in making the diagnosis of ectopic pregnancy, but
  they can be another clue.
• A progesterone level of less than 15 ng/ml is
  seen in 81 of ectopics, 93 of abnormal
  intrauterine pregnancies, 11 of normal
  intrauterine pregnancies.

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Recurrent ectopic pregnancies

• Surgery for small, unruptured ectopics restores
  tubal patency in over 80 of cases.
• After one ectopic and a tubal sparing surgery
• The subsequent delivery rate is about 55-60.
• The recurrent ectopic rate is about 15
• The infertility rate is about 25-30.
• If the other tube is absent or blocked
• The subsequent delivery rate is about 45-50.
• The recurrent ectopic rate is about 20
• The infertility rate is about 30-35.
• As a woman has more and more ectopics, the
  chances for a delivery (without treatment) become
  less and less.

• Medical Therapy - Methotrexate
• Methotrexate inhibits rapidly growing cells such
  as a pregnancy or some cancer cells.
• Most side effects seen with low-dose MTX therapy
  have been mild and transient.
• Good results with very few side effects are seen
  with use of a single IM dose of 50 mg/square
  meter.
• Resolution of the ectopic has been reported in
  about 70-95 of cases treated. This depends
  somewhat on selection criteria for the study.

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Risk factors for ectopic pregnancy

• Most common risk factor for ectopic pregnancy
  -Previous pelvic inflammatory disease. Mechanisms
  include
• - Destruction of tubal ciliated epithelium
  resulting in reduction or loss of the ciliary
  current.
• - Intratubal adhesions resulting in partial tubal
  obstruction.
• - Peritubal adhesions resulting in restricted
  tubal motility.

• Other risk factors
• Previous pelvic surgery
• Particularly reconstructive tubal surgery
• Developmental abnormalities
• diverticulae, accessory ostia and tubal
  hypoplasia
• Adjacent tumors
• especially in the broad ligament resulting in
  distortion, stretching or partial obstruction of
  the tube
• Previous ectopic pregnancy
• Intrauterine contraceptive device