Obgyn · Year 3 · from Obgyn
Case 1: Ectopic Pregnancy
Patient Demographics
- Age: 27 years
- Sex: Female
- Occupation: Physical therapist
Chief Complaint
"I have right-sided pelvic pain and some spotting. I might be pregnant."
History of Present Illness
The patient reports her last menstrual period was 7 weeks ago. She has had 5 days of right-sided pelvic pain that is sharp and intermittent. She noticed light vaginal spotting 3 days ago. She took a home pregnancy test yesterday, which was positive. She denies heavy bleeding, fever, or shoulder pain. She rates her pain 5/10 and has been managing with ibuprofen.
Past Medical History
- Chlamydia infection treated 3 years ago
- Appendectomy at age 16
- No other surgeries
Obstetric/Gynecologic History
- G2P0010 (one prior spontaneous abortion at 8 weeks, managed expectantly)
- Copper IUD removed 4 months ago when she began trying to conceive
- Regular 28-day menstrual cycles
Risk Factors for Ectopic Pregnancy
- Prior chlamydia infection (tubal damage)
- Prior IUD use (if pregnant while IUD in place, higher ectopic rate - but IUD now removed)
- Prior pelvic surgery (appendectomy)
Physical Examination Findings
- Vital Signs: BP 118/74 mmHg, HR 82 bpm, Temperature 98.4F, stable
- Abdomen: Soft, mild right lower quadrant tenderness, no rebound or guarding
- Pelvic: Minimal dark blood at introitus, cervix closed, right adnexal tenderness without palpable mass, mild cervical motion tenderness
Diagnostic Workup
- Urine pregnancy test: Positive
- Quantitative beta-hCG: 2,850 mIU/mL
- Hemoglobin: 12.4 g/dL
- Blood type: O positive, antibody screen negative
- Transvaginal Ultrasound:
- No intrauterine pregnancy visualized
- Endometrial stripe 10 mm
- Right adnexal mass 2.5 cm with "ring of fire" vascularity (tubal ring sign)
- Small amount of free fluid in posterior cul-de-sac
- Left ovary normal
Diagnosis
Right Tubal Ectopic Pregnancy
- Beta-hCG above discriminatory zone (1,500-2,000 mIU/mL) with no IUP
- Adnexal mass with characteristics of ectopic pregnancy
- Small amount of free fluid (minimal hemoperitoneum)
Treatment Options Discussed
Medical Management with Methotrexate: Eligibility assessment:
- Hemodynamically stable: YES
- Beta-hCG <5,000 mIU/mL: YES (2,850)
- Ectopic size <4 cm: YES (2.5 cm)
- No fetal cardiac activity: YES
- Able to comply with follow-up: YES
- No contraindications (immunodeficiency, liver disease, breastfeeding): NONE
Surgical Management:
- Laparoscopy with salpingostomy or salpingectomy
- Indicated if: unstable, contraindications to MTX, or patient preference
Management Plan (Patient Chose Medical Management)
Pre-treatment Workup:
- CBC, liver function tests, creatinine: All normal
- Blood type confirmed: O positive (RhoGAM not needed)
Methotrexate Protocol (Single-Dose):
- Methotrexate 50 mg/m2 intramuscularly = 85 mg (BSA 1.7 m2)
- Administered after counseling
Post-Treatment Instructions:
- Avoid alcohol, folic acid supplements, NSAIDs
- No intercourse until beta-hCG undetectable
- Avoid sun exposure (photosensitivity)
- Pelvic rest
- Return immediately if severe pain, heavy bleeding, dizziness
Follow-up Protocol:
- Beta-hCG on Day 4: 3,100 mIU/mL (may initially rise - expected)
- Beta-hCG on Day 7: 2,100 mIU/mL (28% decrease - SUCCESS requires >15% drop)
- Weekly beta-hCG until undetectable
Clinical Course
- Day 7 beta-hCG showed appropriate decline
- Serial weekly levels continued to drop
- Beta-hCG undetectable at 6 weeks post-treatment
- Counseled to wait 3 months before attempting pregnancy (folate repletion)
- Future pregnancy: early ultrasound to confirm intrauterine location
Clinical Image
Image Description: Transvaginal ultrasound image demonstrating an empty uterus with a "tubal ring" sign in the right adnexa, representing an ectopic pregnancy. The ring of fire pattern on color Doppler shows increased vascularity around the ectopic gestational sac.
Attribution: Image from Radiopaedia. Case courtesy of Dr. Yuranga Weerakkody. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/tubal-ectopic-pregnancy