A 28-year-old woman, gravida 3 para 3, comes to the emergency department with severe abdominal pain in the left lower quadrant and vaginal bleeding. She is saturating a pad every 3-4 hours. Her last menstrual period was 6 weeks ago. Past surgical history is significant for 3 cesarean deliveries and permanent sterilization via a bilateral tubal ligation. A urine pregnancy test is positive, and an ultrasound shows a 2-cm mass in the left adnexa adjacent to the ovary and a thickened endometrial stripe. If a uterine curettage is performed, which of the following findings would be expected in this patient?

Question

A 28-year-old woman, gravida 3 para 3, comes to the emergency department with severe abdominal pain in the left lower quadrant and vaginal bleeding.  She is saturating a pad every 3-4 hours.  Her last menstrual period was 6 weeks ago.  Past surgical history is significant for 3 cesarean deliveries and permanent sterilization via a bilateral tubal ligation.  A urine pregnancy test is positive, and an ultrasound shows a 2-cm mass in the left adnexa adjacent to the ovary and a thickened endometrial stripe.  If a uterine curettage is performed, which of the following findings would be expected in this patient?

Quizplus · Accepted Answer

11ec160b_3793_d822_9249_b75b7efe2097_MD0001_00 Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterus. The most common site is the ampulla of the fallopian tube, which may appear as an adnexal mass on ultrasound. Risk factors include tubal pathology, such as from previous infection or surgery (eg, tubal ligation). Pregnancy after permanent sterilization is extremely rare, but one-third of cases are ectopic if implantation occurs. An ectopic pregnancy may become life-threatening as the embryo and trophoblastic tissue proliferate. This growth will compromise the blood supply to the surrounding tissues, which can result in rupture and profuse intra-abdominal bleeding. A ruptured ectopic pregnancy is managed surgically by removing the pregnancy and achieving hemostasis. Dilation and curettage of the uterus may be performed either to stop uterine bleeding or confirm whether the pregnancy is intrauterine or ectopic. In an ectopic pregnancy, the uterine specimen would reveal decidualized endometrium only, consistent with dilated, coiled endometrial glands and vascularized edematous stroma. These changes occur in the luteal phase of the menstrual cycle, under the influence of progesterone, as the endometrium prepares for implantation. Embryonic and trophoblastic tissue will be absent from the uterus. (Choice A) The finding of atypical endometrial cells that form glands would suggest endometrial adenocarcinoma, a malignancy that typically occurs in postmenopausal women and manifests with vaginal bleeding. (Choice C) A molar pregnancy or spontaneous abortion may present with vaginal bleeding. Uterine curettage may show enlarged chorionic villi and avascular edematous stroma. In contrast, intrauterine chorionic villi are absent in an ectopic pregnancy. (Choice D) An inflammatory endometrial infiltrate would suggest endometritis, an infection of the decidua, which presents with uterine tenderness, fever, and tachycardia. An ectopic pregnancy is not an infectious process. (Choice E) Straight, short endometrial glands and compact stroma are found in the early proliferative phase of the menstrual cycle. This microscopic appearance would be observed 4-7 days after the onset of menses. Educational objective: An ectopic pregnancy is characterized by implantation outside of the uterus. Uterine curettage would reveal decidual changes in the endometrium due to progesterone secretion but no embryonic or trophoblastic tissue (eg, no villi). __________ References: Decidualization of the human endometrium: mechanisms, functions, and clinical perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/17960529)

A 28-Year-Old Woman, Gravida 3 Para 3, Comes to the Emergency