Ultrasound Case #9 – The Bleeding Transfer
A 27Y G4P2 female presented to an OSH with heavy vaginal bleeding and hypotension. At OSH she had a transvaginal ultrasound done that was concerning for ruptured ectopic pregnancy. On an ED to ED phone call the outside Dr. states that radiology read the ultrasound as “a previously present (2 weeks ago) IUP is now absent and there is a 2×4 cm complex mass adjacent to the left adnexa concerning for heterotopic pregnancy.” He notes that there is no mention of free fluid on the read. A unit of PRBCs is started at the OSH and she is transferred to your ED.
Upon arrival to your ED she is hypotensive 80/50 with 1 U PRBCs infusing. She doesn’t know when her LMP was definitively, but her best guess puts her around 14 weeks. She is complaining of abdominal pain and continued vaginal bleeding. You obtain a bedside ultrasound.
What do you see?
What do you see in these images and what is your next step in management?
Click to reveal answer
The images show an incomplete abortion with tissue within an open cervical canal. This is a sad case but represents the importance of identifying all relevant anatomy when performing an ultrasound. The advantage we have in POCUS vs radiology is we are physically at the bedside and can clarify any confusing parts of the image. The first few clips it is not clear how all the structures are connected and this “complex mass” could easily be mistaken for something outside of the uterus. As we change to the sagittal orientation in the last few images you can tell that there is tissue within the uterus, traversing the cervix (which is open) and remaining in the vagina. There is only a small amount of pelvic free fluid, making a ruptured ectopic unlikely as the cause of her hypotension.
Click to reveal learning points
The main point of this post is recognizing the anatomy and connecting the dots.
In the transverse view of the uterus you should be seeing bladder in front of the vaginal stripe that then connects to the uterus as you fan more cranial. (see image below)
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