Emergency Ultrasound Diagnosis of Ruptured Ectopic Pregnancy

A 39-year-old woman with no significant medical history presented to the emergency department with sudden-onset lower abdominal pain. Her last menstrual period was 8 weeks prior, and she had seen her primary care physician 5 days earlier and been told she had a positive pregnancy test. She also complained of lightheadedness, but denied vaginal bleeding and loss of consciousness. Her initial heart rate was 72 beats/min, and her blood pressure was 89/50 mm Hg. She had significant midline lower abdominal tenderness with guarding and rebound tenderness.

After intravenous access was obtained and fluid resuscitation initiated, a bedside abdominal ultrasound was performed by the emergency physician using a 5-2 MHz curvilinear array transducer (Model HD11XE, Philips, Andover, MA). Examination of the hepatorenal recess (Morison’s pouch) demonstrated an anechoic fluid collection consistent with free intraperitoneal fluid (Figure 1 and Video Clip S1). Examination of the pelvis demonstrated an empty uterus with a left adnexal gestational sac and fetal pole consistent with ectopic pregnancy (Figure 2 and Video Clip S2). Color power Doppler demonstrated increased flow around the adnexal mass, a finding known as a “ring of fire” (Video Clip S3). The patient was taken emergently to the operating room where 2 L of hemoperitoneum was found, as well as an ectopic pregnancy in the left fallopian tube. A left salpingectomy was performed and the patient recovered uneventfully.

Figure 1.  Free fluid (ff) visualized in Morison’s pouch between the liver (L) and kidney (K)

Figure 2.  Transabdominal image of the pelvis in a transverse orientation demonstrates an empty uterus (u) with an adjacent left adnexal gestational sac (s) with fetal pole (*).