This week’s VOTW is brought to you by… none other than our fantastic ED Medical Director Dr. Nubaha Elahi and Dr. Waters!
A 44 year old female G5P3 w/ hx of Essure procedure (a 99.3% effective method of contraception) presented to the ED with bilateral eye swelling x1 week. She also had a positive home pregnancy test and vaginal spotting. Without being mislead by the initial chief complaint on a busy fast-track shift the team performed a POCUS of the pelvis which showed...
Clip 1 shows a transabdominal view of the uterus with an empty gestational sac and a thick walled complex R adnexal cyst/mass. In the setting of a bHCG of 37000, this is concerning for an ectopic pregnancy!
Clip 2 shows a transvaginal view of the uterus with an eccentrically located gestational sac containing a fetal pole. Given the concern for interstitial ectopic, the team measured the endomyometrial mantle thickness (nice!) which was 1cm (still within normal range, however approaching the 8mm cutoff).
**The Essure procedure involved inserting metal coils in bilateral fallopian tubes to cause scarring. In 2018 it was taken off of the market because it was associated with many complications including ecotpic pregnancies.
Endomyometrial mantle thickness measurement
Interstitial ectopic
An interstitial ectopic is a pregnancy implanted in the myometrium. It carries a higher rate of shock and hemoperitoneum and higher maternal mortality compared to the other ectopic pregnancies due to the highly vascular myometrium (1)
Think about interstitial ectopic pregnancy if you see an eccentrically placed gestational sac and measure the EMM.
Endomyometrial mantle (EMM) measurement
EMM = thickness of the endometrium + myometrium
Measure from outer edge of the gestational sac to outer edge of the uterus at the THINNEST portion that you see (image 1)
EMM <8mm is concerning for an interstitial ectopic pregnancy
Back to the patient
OBGYN was consulted who admitted the patient for a laparoscopic hysterectomy. The final diagnosis was right interstitial ectopic pregnancy!
We’ve reviewed many ectopic pregnancy cases caught on POCUS recently- an example of a diagnosis where POCUS truly is saving lives! Keep up the great work!
References:
Rastogi R, Gl M, Rastogi N, Rastogi V. Interstitial ectopic pregnancy: A rare and difficult clinicosonographic diagnosis. J Hum Reprod Sci. 2008 Jul;1(2):81-2. doi: 10.4103/0974-1208.44116. PMID: 19562051; PMCID: PMC2700669.