POCUS: early diagnosis of ruptured ectopic

A healthy woman at 5 weeks pregnancy presents with one day of recurring syncope and abdominal pain, no vaginal bleeding, BP 80/40.

On POCUS

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With an unstable early pregnant patient with free fluid in the abdomen, I was able to diagnose a presumed ruptured ectopic at the bedside, cross-match blood and call Gynecology. This was before any labs came back, which were unhelpful anyway as the initial Hgb was falsely reassuring at 120–but by the time she was out of the OR a couple of hours later it was in the 60s.

Had I relied on the initial Hgb or called in a radiology tech after hours for a formal ultrasound, it could have been a disaster. POCUS saved the patient, and is essential in the early diagnosis of ectopic pregnancy.

 

A couple of articles on the importance of POCUS for rapid diagnosis/treatment of ruptured ectopic:

  1. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. 2001 Apr;8(4):331-6. In a retrospective review of ruptured ectopics going to the OR, those identified as having free fluid in the RUQ at the bedside (instead of going to radiology for formal ultrasound) had their diagnosis made 2.25 hours earlier, and operative treatment 3.5 hours earlier.
  2. Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention Suspected Ectopic Pregnancy. Acad Emerg Med; 2007 Aug;14(8):755-758. In a prospective analysis of 242 patients with first trimester bleeding in whom 28 were ectopic and 18 required surgery, the emerg physician found free fluid in Morrison’s pouch in 10 patients, nine of which required OR. There were no clinical predictors that differentiated ectopics requiring OR vs non-OR (page, HR, BP, beta, Hgb), but free fluid in Morrison’s pouch had a positive likelihood ratio of 112 for OR.

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