MOC April 2015: Abdominal Pain in 41 y.o. Female

History

A lovely young married couple comes in to triage and the 41-year-old woman is complaining of abdominal pain.  It is left sided and she rates it as 7/10 at its worst.  She recently had her IUD removed but has not taken a pregnancy test.  Does not have any recollection of last menstrual period.  She is otherwise healthy and not on any medications.

Associated symptoms include nausea without vomiting.

She denies any vaginal bleeding or discharge.  Denies urinary symptoms.  Denies fevers.

Social History

She is a full-time mom with her 5 year old son.  No history of smoking, no alcohol use, no drug use.

Allergies

NKDA

Medications

She is on no medications.

Physical Exam

Vital Signs: Temp 99.0°F, HR 90, BP 119/69, SpO2 99% on room air, Wt: 68 kg, Ht 165 cm

Patient is alert and oriented x3.  She has normal heart and lung exam. 

Abdominal exam: LLQ tenderness with mild, voluntary guarding.  Mild suprapubic tenderness.

Pelvic exam: left adnexal tenderness without palpable mass.  Cervical os is closed.  No cervical motion tenderness.  No discharge or bleeding.

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What is your differential diagnosis so far?

Ovarian cyst, ovarian torsion, ectopic pregnancy, threatened miscarriage, UTI, pyelonephritis, diverticulitis, colitis, others.

What testing will you do on this patient?

•   UPT

•   Urinalysis

•   +/- CBC, CMP, BMP, Lipase

•   +/- Wet prep, GC Chlamydia

•   Pelvic US

UH OH!  UPT comes back positive!  How does this change your plan?

•   Now definitely get an ultrasound.

•   UA - unremarkable.

•   CBC, CMP, Lipase unremarkable.

•   Wet prep negative, GC chlamydia pending

•   Add on beta quant HCG and Rh (+/-)

The ultrasound tech is being called in, so you are still waiting.

•   Beta quant: 15,000+

•   Rh positive

Updates
The ultrasound tech calls to tell you, "this is a weird ultrasound, can you look at it?"  You look at the ultrasound.  Here is what you see:

What is your diagnosis?

•   Heterotopic pregnancy

WHAT THE HECK?!  This wasn't even on your differential!  What do you do now?

•   CALL OB STAT!

•   Keep patient NPO.

•   Order pre-op labs etc.

•   IV Access.

•   Pain control.

•   OB is coming down to the see the patient and plans to take her to surgery tonight.

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QUESTIONS:

1)   Is the incidence of heterotopic pregnancy more, less, or the same in 2015 than 20 years ago?

a)    Much more - Prevalence is 1 in 30,000 in the non-fertility drug utilizing population and 1.5 in 1000 (!) in the fertility treatment utilizing population (including medications, insemination, etc).  Overall incidence is 1 in 3900.

2)   Which of the following are risk factors for heterotopic pregnancy?

a)    History of PID

b)   History of UTI

c)    Use of fertility treatments (Clomid, IVF, insemination)

d)   History of bacterial vaginosis

3)   What are the two possible treatments for heterotopic pregnancy?

a)    Surgical removal of the ectopic (salpingectomy)

b)   If not ruptured, potassium chloride may be injected into the site under sonographic guidance

4)   How likely is it that this patient will lose her IUP?

a)    She has a 25% chance of survival of the IUP.

5)   What ectopic pregnancy treatment is contraindicated in heterotopic pregnancy?

a)    Methotrexate therapy is contraindicated with the presence of a potentially viable IUP.

So what is a heterotopic pregnancy?

•   This is a rare condition in which two gestational sacs form - one ectopic and one intrauterine.  It can actually also be two separate ectopic pregnancies.

•   Prevalence is 1 in 30,000 in the non-fertility drug utilizing population and 1.5 in 1000 (!) in the fertility treatment utilizing population (including medications, insemination, etc).  Overall incidence is 1 in 3900.

•   Most common with fertility treatments (ANY fertility treatment), but can happen in patient's who do not use fertility treatments.

•   Definitive treatment is removal of the fallopian tube to attempt to save the IUP.  Chance of the IUP surviving is approximately 25%.  If not ruptured, potassium chloride may be injected into the site under sonographic guidance.

Outcome

Patient had her left fallopian tube removed and did end up losing the IUP.  She plans to follow up with OB for fertility treatments in the future as they would like to have one more child.  She is at increased risk of further ectopic or heterotopic pregnancies in the future.