A 34-year-old woman comes to the emergency department for vaginal bleeding. The patient initially had vaginal spotting yesterday, but the bleeding has become increasingly heavy. She also has had lower abdominal pain with nausea for the past hour. Her last menstrual period was 7 weeks ago. She is sexually active and does not use contraception due to a history of infertility. The patient has had no surgeries and takes no daily medications.
Blood pressure is 100/50 mm Hg and pulse is 92/min. BMI is 41 kg/m². The abdomen is tender in bilateral lower quadrants with involuntary guarding. Pelvic examination reveals a closed cervix with active bleeding from the cervical os. Bimanual examination reveals a small, mobile uterus and right adnexal tenderness.
Hemoglobin is 9.8 g/dL and quantitative β-hCG is 7,135 IU/L. Transvaginal ultrasound shows a thickened endometrial stripe, a 4-cm complex right adnexal mass, and a small amount of free fluid in the posterior cul-de-sac.
Which of the following is the most likely diagnosis in this patient?

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Quizplus · Accepted Answer

11ec193a_95ff_f56e_853d_2d3e800c89ed_MD0002_00 This patient likely has an ectopic pregnancy based on first-trimester vaginal bleeding, lower abdominal pain, and a complex adnexal mass on transvaginal ultrasound. Risk factors for ectopic pregnancy include prior pelvic surgery, pelvic inflammatory disease, infertility, and tobacco use. Common implantation locations for an ectopic pregnancy include the fallopian tubes, ovaries, and cornua of the uterus. implantation locations As the ectopic gestation develops, extrauterine implantation sites cannot adapt to the rapid increase in gestational size, and rupture can occur. A ruptured ectopic pregnancy is a life-threatening emergency due to intra-abdominal bleeding (eg, anemia, free fluid in the posterior cul-de-sac) and resultant hemodynamic instability. In hemodynamically stable, reliable patients, an ectopic pregnancy can be either expectantly or medically (eg, methotrexate) managed. Expectant management is primarily for patients with no adnexal mass on ultrasound and a β-hCG ≤200 IU/L. Methotrexate can be used in patients with no medical contraindications to therapy (eg, immunodeficiency, renal failure, active pulmonary disease) and a β-hCG ≤5,000 IU/L. In contrast, hemodynamically unstable patients, such as this one, require surgical management (eg, laparoscopy). (Choice A) Abruptio placentae can cause vaginal bleeding and lower abdominal pain; however, this typically occurs in the third trimester and has associated uterine tenderness. Abruptio placentae (Choice B) A complete hydatidiform mole presents with first-trimester vaginal bleeding; however, patients typically have an enlarged uterus, markedly elevated β-hCG (>100,000 IU/L), and an intrauterine heterogeneous mass with cystic areas (ie, snowstorm appearance) on ultrasound. hydatidiform mole (Choice D) An incomplete abortion can present with heavy vaginal bleeding, resulting in hemodynamic instability. However, patients have a dilated cervix with partial expulsion of the pregnancy. This patient has a closed cervix. incomplete abortion (Choice E) Pelvic endometriosis can cause complex adnexal masses (eg, endometrioma); however, patients typically have regular, painful menses and an immobile uterus. Educational objective: Patients with a ruptured ectopic pregnancy typically have first-trimester vaginal bleeding, lower abdominal pain, hemodynamic instability, and a complex adnexal mass. A ruptured ectopic pregnancy is managed with surgery. __________ References: Reevaluation of discriminatory and threshold levels for serum ß-hCG in early pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/23262929) Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28620520)

A 34-Year-Old Woman Comes to the Emergency Department for Vaginal