A pregnant female presented for possible appendicitis. She had a 1 day history of right lower quadrant abdominal pain, vomiting, hematochezia, and mild urinary frequency. She denied fevers, chest pain, shortness of breath, back pain or vaginal bleeding/discharge. She received in-vitro fertilization approximately 8 weeks prior to presentation. Her vital signs were normal, and she had mild abdominal tenderness in the right lower quadrant. Providers were looking to rule in appendicitis, but that’s not how it went.
A POCUS transabdominal pelvic study was performed to confirm the intrauterine pregnancy (IUP). Image 1 below shows an IUP.
Image 1: POCUS Transabdominal longitudinal view meeting IUP criteria; Two organs, bladder to screen right, uterus to the left. Within the uterus there is a gestational sac, fetal pole within that gestational sac, and an endomyometrial mantle that [though not measured] is greater than 8mm.
On the POCUS Transabdominal Pelvic transverse image (Image 2) below there is a concerning circular structure adjacent to the uterus on the right, findings suspicious not for appendicitis, but for a heterotopic pregnancy, seeing a possible second gestational sac with what was thought to be the faint outline of a yolk sac within (Image 3).
Image 2: POCUS Transabdominal pelvic view showing IUP and concerning right sided adnexal structure.
Image 3: Right sided adnexal circular structure concerning for second gestational sac with possible yolk sac within (not definitive, but concerning).
Providers moved to evaluate the hepatorenal space to ensure no free fluid. POCUS, however, did show free fluid and she was taken to the operating room where she was found to have a right tubal ectopic pregnancy with 300cc’s of hemoperitoneum. She required a salpingectomy and months later delivered a healthy baby.
Image 4: Free fluid in the hepatorenal space of the right upper quadrant, seen as anechoic (black) jagged edged collection between liver and kidney.