Review Question - QID 214632

The patient's findings of nausea, vomiting, unilateral lower abdominal pain, a positive urine β-hCG, and adnexal tenderness in the setting of sexual activity with inconsistent barrier protection, a history of pelvic inflammatory disease, and 2 missed menstrual periods suggest ectopic pregnancy. A transvaginal ultrasound will likely demonstrate an empty uterine cavity.

Ectopic pregnancies are caused when a fertilized egg implants outside of the uterus. Ectopic pregnancies are most often caused by the failure of an egg to pass through the Fallopian tubes properly, usually from prior Fallopian tube damage, such as pelvic inflammatory disease, smoking, or endometriosis. Patients may present with amenorrhea, nausea, vomiting, abdominal pain, adnexal tenderness, and vaginal bleeding. The diagnosis of ectopic pregnancy is confirmed with an elevated serum β-hCG level and transvaginal ultrasound demonstrating an absence of products of conception in the uterus. Generally, if a serum β-hCG level is ≥ 1,500 IU/L, transvaginal ultrasound should demonstrate intrauterine products of conception; if there are none, suspicion increases for other pathologies such as an ectopic pregnancy. Treatment involves medication (methotrexate) or surgery, depending on the patient's hemodynamic stability. Surgery may involve removal of the entire Fallopian tube (salpingectomy) or a simple incision with preservation of the tube (salpingotomy/salpingostomy).

Incorrect Answers:
Answer 2: Enlarged, edematous right ovary with absent arterial flow suggests ovarian torsion. Ovarian torsion occurs when an ovary twists around other pelvic structures, obstructing its blood supply, and presents with sudden unilateral, sharp pain, often with nausea and vomiting. Treatment involves surgery.

Answer 3: Gestational sac and fetal pole in the uterus are consistent with a normal pregnancy. Normal pregnancy can present with fatigue, nausea, vomiting, breast tenderness, and spotting. Mild abdominal pain can occur; severe abdominal pain is unusual.

Answer 4: Mildly dilated appendix may be seen on ultrasound in patients with appendicitis. Appendicitis occurs when the appendiceal lumen is blocked and becomes infected. Appendicitis typically presents with lower right-sided quadrant pain, fever, anorexia, nausea, and vomiting. Missed menstrual periods, a positive urine β-hCG, and a lack of fever in this patient render appendicitis less likely as a cause for this patient's symptoms.

Answer 5: Unilateral echogenic mass with calcifications suggests an ovarian teratoma. Ovarian teratomas are germ cell tumors made up of multiple tissue types. They are often asymptomatic but may present with abdominal pain, bloating, a palpable mass, and abnormal uterine bleeding. Treatment may consist of surgery and possibly chemotherapy.

Bullet Summary:
Ectopic pregnancy presents with nausea, vomiting, unilateral lower quadrant abdominal pain, and amenorrhea; an empty uterus may be seen on transvaginal ultrasound.