ED Case

[Groove]

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ER doc here and looking for some input.

G1Po, 28yo female, LMP 2 months ago or roundabouts. Spotting for a month with passage of larger amounts of blood over the last week with what looks like clots. BHCG ~2000. Mild abdominal cramping over the past couple of days but benign abd exam. Pelvic with scant clotted blood in the fornix but relatively normal. US with nothing in the uterus, no adnexal mass, no free fluid, nothing.

I'm thinking complete miscarriage. F/U with OB and repeat BHCG and US in 2 days just to be sure.

PT comes in 2-3 weeks later with abd pain. This time the abd pain is more severe and she is having cramping. I did not see the pt during this visit so I have very little info on the exam itself. BHCG is 47. Ob consulted and at first thought nothing of it but then decided to take to OR for diagnostic lap. This is after a repeat US with nothing and no adnexal mass. OR report shows a R adnexal mass that was removed with pre/post operative dx of ectopic. Path report shows tube, blood, relatively non descript and no fetal tissue or parts.

1) Ectopic or some other pathology going on here? Terminated in the fallopian perhaps?

2) Would you expect BHCG 2000 with a relatively new miscarriage of those dates?

3) HCG 2000 is above discrim zone. I would have expected the US to see something. Flawed US?

4) Overzealous dx by surgeon?

I'm a bit baffled on this one so I thought I would run it by you guys.

Thanks.

 

[anonperson]

I'll say that radiology is usually kind of weak in general when it comes to pelvic ultrasounds, especially pregnancy related. I'd have to look at the images myself to see what the stripe looked like (thickened, evidence of even a questionable gestational sac etc) to make a decent call. I know 1500-2000 is technically the discriminatory zone but that can be hit or miss depending on the sonographer and the radiologist.

I guess I am confused as to what prompted the OB to take the patient to the OR with a quant of 47. Either the exam was concerning or the ultrasound showed free fluid (I know you said it was commented as normal but if they reviewed it and thought there was something off) when they reviewed it or the patient's Hgb was significantly decreased. Concerning the OR trip, was there blood in the abdomen? Was the tube ruptured? Since they don't have any fetal tissue/chorionic villi it's hard to say, although I am not sure if you would see anything with a quant of 47.

Regardless, I don't personally feel there was any issues with the initial management. The differential in this situation is still threatened abortion vs completed abortion vs ectopic. With a benign exam and nothing on the ultrasound, it's hard to jump to laparoscopy or methotrexate for a possible ectopic pregnancy.

Did the patient follow up for the quant in 48 hours?

I actually had a very similar case. Quant of 2300. Patient came in with bleeding and cramping. Maybe passed tissue at home but since being in the ED for a few hours did not have any significant pain. Vitals and labs were otherwise normal. U/S showed maybe a questional sac vs polyp but nothing else. Exam was completely benign. Gave her precautions with instructions to get a quant in 48 hours. Of course this patient was from out of town and was going back home. Her phone number that she gave isn't accepting calls, so I'm hoping she followed up, but you can only help people so much.

Reharding your questions:
1)Hard to determine. The op report would give the best information. If there was evidence of hemoperitoneum and a blown tube, then most likely an ectopic
2)If she had just passed tissue, you can still have a relatively high beta. It can take a bit of time and the half life varies for beta hcg.
3)Potentially flawed ultrasound or an accurate ultrasound with nothing in the uterus. Hard to say without looking at the images
4) Hard to say without looking at the H and P (maybe they felt there was cervical motion tenderness etc)

Sorry the answers aren't more definitive.

 

[THP]

Definitely an odd scenario. I think the initial management was fine. It is certainly possible to have a beta around 2000 shortly after a completed SAB with a normal US especially given her LMP . It seemed like her beta was dropping normally when she came back in. It would have been nice if she kept a f/u in the gyn office.

One other possibility is that she developed a hemorrhagic corpus luteum causing pain or developed ovarian torsion. There probably would have been mention of that with the pathology though.

She could have had a tubal abortion (terminated in the fallopian tubes) but you almost always see fluid in the cul-de-sac on US. Sometimes the pathology in these will not show chorionic villi but will usually be able to see an implantation site effect in the tube. The pathologist can do an immunostain for HCG to confirm the site. But if she were hemodynamically stable, no fluid or cyst on US, and falling HCG I'm not sure why he took her for surgery.

In summary, must have been something in the exam that made him want to take her to the OR unless the US just missed it. I have no idea otherwise.

 

[Groove]

Excellent, thanks for the input.

 

[Ralph]

Excellent, thanks for the input.

I guess the initial diagnosis of Pregnancy of Unknown origin is made when seen at ED.So it's either Complete intrauterine miscarriage vs tubal abortion vs ectopic.
With a hcg of 2000 you should ideally see a sac or evidence of pregnancy so not seeing that will get me somewhat suspicious but then again it could still be a complete miscarriage so with a pretty normal exams and obs.Warning signs are given to be reviewd at the Early pregnancy unit for serial hcg and scans.
So obviously hcgs falling to 47 within 48hrs points more towards some sort of abortive process which could still be intrauterine or tubal so ideally if patient is still haemodynamically stable n scan is still showing an empty uterus and no adnexal mass or free fluid then repeat hcgs in 48hrs if you still feel concerned or repeat home PT in 1 or 2 weeks with still warning signs and advise to return if + ve.
But as she was taken to OR I would have done both a dia Lap and a uterine evacuation just in case to confirm an intrauterine preg if pathology doesn't show ectopic bcos the pathologist will definitely see a placental site reaction in the endometrium if it intrauterine and I would somehow sleep better at home knowing I have covered all holes
Can't say if surgeon over zealous bcos sometimes you just clinically go with what is presented to you and go with what you perceive is wrong and manage accordingly

Anyway you did well and quite sometimes things like this do happen but the lesson is just consent and do an Evac also just in case.
That is how we do it in England anyway