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By Phillips Perera, MD, RMDS, and Diku Mandavia, MD, FACEP, FRCPC
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Presentation:
A 24-year-old woman presents to the emergency department with a chief complaint of vaginal bleeding and lower abdominal cramping. She is sitting on a stretcher and appears relatively comfortable. A quick history reveals she is a G3P2, had her last menstrual period six weeks ago, and has no history of ectopic pregnancy or fertility treatments. She just learned she was pregnant when the nurse checked her urine. Vital signs are: heart rate, 84; blood pressure, 110/70; temperature, 998 F. An ultrasound machine is used to obtain the following transvaginal image.
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Diagnosis and discussion:
The ultrasound image here shows an intrauterine pregnancy (IUP). The presence of vaginal bleeding with a confirmed IUP clinches the diagnosis of a threatened abortion. An IUP is best identified by the presence of a circular yolk sac inside a larger gestational sac. The gestational sac is the earliest structure formed in pregnancy, but it is not specific for an intrauterine pregnancy because it can also be generated by hormonal stimulation of an ectopic pregnancy (pseudogestational sac).
As the pregnancy develops beyond six weeks, features such as the fetal pole and fetal heart beat can be appreciated within the gestational sac. This combination of findings rules out ectopic pregnancy with a high degree of certainty; the risk of an associated heterotopic pregnancy (a second pregnancy in an abnormal location) is estimated at 1:8000. The risk is higher in patients with a history of fertility treatments or ectopic pregnancy, and an ob/gyn consult and comprehensive ultrasound should be obtained in such cases. In patients diagnosed with a threatened abortion in whom a fetal pole with heartbeat can be appreciated, the risk of progressing to a completed abortion is less than 5%.
In this case, the bleeding and abdominal cramping resolved over the next few days. Follow-up ultrasound one week later showed the presence of a fetal pole with heart beat, further indicating a good prognosis to our patient. |
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Dr. Perera is an assistant clinical professor of emergency medicine at Columbia University College of Physicians and Surgeons and Weill Cornell Medical College and director of emergency ultrasound at New York Presbyterian Hospital in New York City. Dr. Mandavia is a clinical associate professor of emergency medicine and director of emergency ultrasound at Los Angeles County-USC Medical Center and an attending staff physician at Cedars-Sinai Medical Center in Los Angeles.
Emerg Med 39(9):11-12, 2007
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