Clip 1: Repeat POCUS Hepatorenal Space, positive for free fluid.
Clip 2: POCUS Transvaginal without IUP and positive for free fluid enveloping the uterus.
A female in her 20s presented with several hours of vaginal bleeding and lower abdominal pain. She had taken a home pregnancy test which was positive. Vitals; Temp of 98.6 F, BP of 96/50 mm/Hg, and HR of 77 bpm. Her abdomen was soft, with rebound tenderness primarily in the LLQ. An initial POCUS of the hepatorenal space was negative. A pelvic exam was performed and was significant for scant vaginal bleeding from a closed cervical os and L adnexal tenderness.
POCUS Transvaginal: No IUP and free fluid surrounding the uterus [Clip 2 above]. A repeat evaluation of the RUQ with the patient in Trendelenburg showed small volume of free fluid along the liver edge [Clip 1 above].
The patient was taken to the OR, and found to have an ectopic pregnancy in the L fallopian tube that had ruptured with an estimated 650cc of hemoperitoneum.
The Evidence: Moore et al found that free fluid in the hepatorenal space predicted operative management, so that’s always the advised first look as was done here. Hick et al showed that VS don’t correlate with hemoperitoneum as manifested by this case [HR 77 bpm on presentation], so don’t be fooled by VS in normal range. Abrams et al found that Trendelenburg positioning increases the sensitivity of finding free fluid in the hepatorenal space.