By Ashley Aiken, Gagandeep Singh
RUQ view of the Fast exam: Large amount of anechoic fluid in Morrison’s pouch and around tip of the liver.
25 y/o F, no PMHx, presented with sudden acute ABD pain radiating to the right shoulder. No home pregnancy test. No vaginal bleeding or urinary symptoms. Pt states she is on OCPs and complaint. Patient’s initial vitals were as follows: BP 115/80, HR 99, Temp 99.1, RR 26, SpO2 99%. Pt was initially triaged to the White Zone. Exam remarkable for diffuse abdominal tenderness with rebound. Pt unable to stay still, writhing in pain, and became diaphoretic, and now tachycardic to 110’s. Subsequently, patient was up triaged to Red Zone, while repeat vitals were being obtain and IV access being established, a POCUS was performed:
Repeat vitals: BP 70/50, HR 120, Temp 99.1, RR 26, SpO2 99%
Transabdominal Ultrasound (not pictured): No IUP, however small amount of free pelvic fluid surrounding the uterus.
Outcome:
GYN was called STAT to ED bedside. Blood bank called for 2 units of O- blood, IVF started. Straight cath Upreg positive. Pt taken as priority case to OR, where she was found to have a ruptured ectopic pregnancy in the left fallopian tube. 2L hemoperitoneum evacuated. Pt remained HDS and was discharged the following day.
POCUS Pearls:
Ectopic pregnancies are the leading cause of maternal mortality in the first trimester. Thus, any female of child bearing age who comes to the ED with complaints of abdominal pain, vaginal bleeding, or syncope should have ectopic pregnancy on the differential, which is a can’t miss diagnosis.
To risk stratify a female patient with acute, undifferentiated abdominal pain we suggest emergency physicians first look to identify free fluid in the hepatorenal space. Free fluid does not definitively rule in a ruptured ectopic pregnancy, but in the context of a positive pregnancy test and no intrauterine pregnancy, it is the diagnosis of greatest concern. While the majority of patients presenting with first-trimester bleeding or pain are stable, a subset may present with a hemorrhagic ectopic pregnancy and are potentially unstable. While much interest in the FAST exam has been focused on trauma, FAST may also indicate significant non-traumatic pelvic and intraperitoneal hemorrhage. Free intraperitoneal fluid found in Morison’s pouch in patients with suspected ectopic pregnancy can be rapidly identified at the bedside by Emergency Physician performed US and predicts the need for operative management.
Ashley’s Takeaways:
To risk stratify a young female with acute, undifferentiated RLQ pain, look to identify free fluid in the hepatorenal space. For a patient with a positive pregnancy test and no definitive IUP observed on US, a comprehensive view of the RUQ should be always obtained by the EP; the presence of intra abdominal free fluid should raise concern for ruptured ectopic pregnancy.
Emergency department RUQ ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies.
Sources:
Moore C, Todd WM, O’Brien E, et al. Free fluid in Morison’s pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007; 14:755-758.
Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View is the Most Sensitive Area for Free Fluid on the FAST Exam.
Rodgerson JD, Heegaard WG, Plummer D, Hicks J, Clinton J, Sterner S. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. 2001; 8:331–6.
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