Send the right patients home with POCUS

Dr. Tim Van Aerde sent us this great case which illustrates some important points.

This lady came in with vaginal bleeding, hCG 2500 and very minor left flank pain. Vitals normal. Hemoglobin normal.

In the past I would have sent this patient home with an ultrasound in the morning. Threw on the probe and saw no IUP but more importantly, free fluid! (interestingly abdominal EDE was negative even in Trendelenberg). So admission and obs consult instead. Turned out to be a ruptured ectopic.

Transabdominal longitudinal view of the uterus showing free fluid in the recto-uterine pouch.

Some take home points:

If the beta-HCG is above discriminatory threshold and there is no visible intra-uterine pregnancy, it is an ectopic until proven otherwise.  Don’t think that stable patients are just early IUPs.  Consider them ectopics then ask yourself how comfortable you are with this particular patient waiting for a semi-urgent ultrasound the next day.  To aid in this decision you should always do the following:

The next step with any potential ectopic is to determine if there are signs of rupture.  That means looking for free fluid in the pelvis and upper quadrants.  Free fluid means urgent consult and/or further imaging.  You have risk stratified this patient to an urgent, inpatient-care pathway.

I have seen experienced POCUS practitioners sometimes forget this important step.  Remember, the pregnant woman has tremendous physiologic reserves and can have completely normal vitals until the moment she crashes.  Even tachycardia can be masked in the hypovolemic patient by a vagal response to the pain of the ectopic.

In addition, the management of a ruptured vs unruptured ectopic may be quite different for the OB-Gyne.  I have had a patient waiting for medical therapy for an ectopic that began to display free fluid in the abdomen  when I reassessed her while she was waiting in the ED.  The consultant took her to the OR instead of sending the patient home.