The Journal of Emergency Medicine, Vol. 39, No. 4, pp. 499 500, 2010 Copyright 2010 Elsevier Inc.

. Printed in the USA. All rights reserved 0736-4679/$see front matter

doi:10.1016/j.jemermed.2008.04.006

Visual Diagnosis in Emergency Medicine

ECTOPIC PREGNANCY AND TUBO-OVARIAN ABSCESS

Turandot Saul,
MD

Department of Emergency Medicine, Emergency Ultrasound Division, St. Lukes/Roosevelt Hospital Center, New York, New York Reprint Address: Turandot Saul, MD, Department of Emergency Medicine, Division of Emergency Ultrasound, St. Lukes/Roosevelt Hospital Center, 1000 Tenth Avenue, Room GE-01, New York, NY 10019

CASE REPORT A 25-year-old woman, G3 P1021, presented to the Emergency Department (ED) with constant sharp left lower quadrant pain for 1 day accompanied by nausea and three episodes of vomiting. She had a history of irregular menses, and her last menstrual period was 6 weeks before this ED visit. The patient had been treated for pelvic inammatory disease (PID) 2 weeks prior, but her partner had not been treated and they continued to have unprotected intercourse. She denied diarrhea, fever, urinary symptoms, vaginal bleeding, or discharge. Vital signs were: blood pressure 100/60 mm Hg, heart rate 110 beats/min, and rectal temperature 38C (101.0F). On physical examination, the abdomen was soft with left lower quadrant tenderness and there was no rebound or guarding. Pelvic examination was signicant for a small amount of white discharge from the cervical os, tender left adnexal mass, and cervical motion tenderness. Laboratory analysis included a hematocrit of 35% and serum -hCG of 652 mIU/mL. She had an ultrasound performed with a presumptive diagnosis of left-sided ectopic pregnancy. A high-frequency endocavitary probe was used to obtain a transvaginal ultrasound (Figures 1-4). The patient was diagnosed with both an ectopic pregnancy and tubo-ovarian abscess. DISCUSSION The differential diagnosis for a pregnant woman who presents with pelvic pain and adnexal mass must include

Figure 1. Uterus: If LMP (last menstrual period) is accurate, we would expect to visualize a uterine gestation. The low -hCG level with the presence of an empty uterus raises the suspicion for ectopic pregnancy.

ectopic pregnancy, ovarian torsion, ovarian cysts and cyst rupture, and tubo-ovarian abscess. Ectopic pregnancy is the leading cause of maternal death in the rst trimester (1). Risk factors include assisted reproduction as well as tubal factors such as previous salpingitis, tubal surgery, and previous ectopic pregnancy (2). PID is an upper genital-tract infection that may affect the fallopian tubes, ovaries, uterus, and peritoneum. The two most common causative pathogens are Neisseria gonorrhea and Chlamydia trachomatis, although the infection is often polymicrobial (3). To make the diagnosis, the patient must have abdominal pain, cervical mo-

RECEIVED: 3 December 2007; FINAL ACCEPTED: 4 April 2008

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Figure 2. Left adnexa: Enlarged tubo-ovarian complex estimated 8 cm in diameter with multiple irregular tubo-ovarian abscesses.

Figure 4. Morrisons Pouch: (arrow) Free uid can be seen in between the liver and right kidney.

tion tenderness, and adnexal tenderness, as well as one of the following: fever 38F (101C), abnormal cervical discharge, elevated erythrocyte sedimentation rate, or C-reactive protein or positive cervical cultures for N. gonorrhea or C. trachomatis. Left untreated, tubo-ovarian abscess, tubal scarring leading to infertility or ectopic pregnancy, or chronic pelvic pain can occur (3). Tuboovarian abscess is not a unique entity but rather a nding along a spectrum of PID (4). Only 5% of patients with PID will progress to abscess formation, and tubo-ovarian abscess is very rarely found in the pregnant patient (5). Pelvic ultrasound has a sensitivity of 93% and a specicity of 98% in its diagnosis (6). Inammation in the tissues makes borders between structures more difcult to identify, and the ultrasonographic nding of

the whole mass may be referred to as the tubo-ovarian complex (4). Ectopic pregnancy is a diagnosis that should be considered in a pregnant patient with abdominal pain. An intrauterine gestation should be visualized on transvaginal ultrasound at a -hCG level of about 1500 mIU/mL. An empty uterus with a -hCG level below this may be an early intrauterine pregnancy. Because ectopic pregnancies develop abnormally, the serum -hCG does not rise as expected and a patient may have surgically and clinically signicant pathology at very low levels. Therefore, ultrasound evaluation in pregnancy must include a thorough evaluation of both adnexa and a high level of suspicion must be maintained if the clinical picture suggests this diagnosis. The free uid in the abdomen indicated that rupture of either the ectopic pregnancy or the tubo-ovarian abscess had likely occurred. The patient was admitted to the Obstetrics and Gynecology service and taken to the operating room for denitive management.

REFERENCES
1. Centers for Disease Control and Prevention. Ectopic pregnancy United States, 1990 1992. MMWR Morb Mortal Wkly Rep 1995; 44:46 8. 2. ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the Emergency Department in early pregnancy. Ann Emerg Med 2003;41:12333. 3. Holland-Hall C. Sexually transmitted infections: screening, syndromes, and symptoms. Prim Care 2006;33:43354. 4. Lambert MJ, Villa M. Gynecologic ultrasound in emergency medicine. Emerg Med Clin North Am 2004;22:68396. 5. Webb EM, Green GE, Scoutt LM. Adnexal mass with pelvic pain. Radiol Clin North Am 2004;42:329 48. 6. Zeger W, Holt K. Gynecologic infections. Emerg Med Clin North Am 2003;21:631 48.

Figure 3. Right adnexa: (arrow) 2.19 cm 2.24 cm structure with internal echoes suspicious for ectopic pregnancy. No fetal heart beat was identied.