Image 1: Morrison’s Pouch: + Free fluid (anechoic stripe) between the liver and right kidney
Clip 1: Caudal tip of the liver: + Free fluid
A young woman presented to the emergency department with right lower quadrant abdominal pain and a minimal amount of vaginal bleeding. She’s pregnant, in her first trimester. The pain started two days prior, described as sharp and initially intermittent, but is now constant. No fevers, nausea, vomiting, lightheadedness, palpitations, or dysuria. The pain radiates to her right leg and right lower back. Her vitals: blood pressure is 110/60, pulse 93, afebrile, 02 100% with a respiratory rate of 18. Her abdomen is tender to palpation in the right lower quadrant.
POCUS Hepatorenal space shows intraperitoneal free fluid in Morison’s Pouch (Image 1) as well as the caudal tip of the liver (Clip 1). No intrauterine pregnancy was identified on trans-abdominal POCUS view of the uterus.
POCUS Pearl: If there is any concern for an ectopic pregnancy, a POCUS assessment of the hepatorenal space is essential. Of note, the caudal tip of the liver is more sensitive than Morison’s Pouch, so if Morison’s Pouch is negative, you must also scan distally to the caudal tip of the liver. There is nothing on HPI or physical exam that can rule out a ruptured ectopic pregnancy. As in this case, a positive POCUS of the hepatorenal space, without an intrauterine pregnancy all but rules in a ruptured ectopic pregnancy. She was taken expeditiously to the operating room and did well.