This patient has a large ectopic pregnancy visible on ultrasound with fetal motion and cardiac activity. The patient was consulted to OB/GYN and they took her to the OR immediately. During her laparotomy, the patient was found to have a large amount of clotted blood in the pelvis (about 1L) and a ruptured right ampullary ectopic pregnancy. She was also noted to have a boggy uterus with adhesions, consistent with PID. The patient had a right salpingo-oophrectomy and was treated with antibiotics.
Ectopic Pregnancy
Ectopic pregnancy is an abnormal pregnancy that occurs outside of the uterus. It is noted to be associated with PID in 50% of cases. Women who have undergone surgical sterilization are at increased risk of ectopic pregnancy, especially after the 2nd year after the procedure. After ectopic, 33% of women go on to later have a normal pregnancy. Another third will have another ectopic. The woman's age, previous successful pregnancies and the cause of a previous ectopic will predict the likelihood of having a successful pregnancy in the future. The mortality rate of ectopic pregnancy in the US has decreased in the last 30 years to less than 0.1%. Note that the placement of the ectopic will determine how rapidly an ectopic will become symptomatic. Those in the fimbrial region will develop more before they become symptomatic due to the fact that that portion of the Fallopian tube is wider than the rest.
It is really important when looking to rule out ectopic that you evaluate the uterus in 2 planes. The ectopic in this case could easily have been missed. The gestational sac and fetus appear so close to the uterus that it would be easy to mistake this pregnancy for one in the uterus. However, when you take a closer look at the video, notice that the endometrial stripe is anterior to the gestational sac and that there is a thin line of anechoic fluid. Taking a few minutes to carefully note where the pregnancy is, can save a lot of trouble in the future!
Let's look at the video again, slowed down a bit and with the areas of interest pointed out. Did you catch it this time?