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You really hope today’s shift is better than yesterday’s. You had to tell a really nice homeless man that internal medicine refused to admit him for his femoral DVT because he doesn’t meet “admission criteria” and that he would have to find the means to pay for his outpatient Lovenox on his own. Then a patient came into the ED with chronic pack pain, and you ended up diagnosing him with metastatic prostate cancer with spinal metastases.
Your next patient seems nice enough. She’s 29 years old and is accompanied by her husband at the bedside. She starts by saying, “Please just tell me my baby is OK. We’ve been trying to conceive all year!” She is a G1P0 who is otherwise healthy and without any co-existing conditions. She came into the ED because she’s been having some mild cramping and some intermittent spotting. Her OB appointment is next week, and she has not had any prenatal care. She is taking over-the-counter prenatal vitamins regularly, and Tylenol to help with her pain. She appears anxious and worried and is hanging on every word, gesture, and movement you make in the room.
Her vital signs are normal and her physical exam is only remarkable for some mild suprapubic tenderness on palpation, and a scant amount of blood near her closed cervix in her vaginal vault. You send off a serum quantitative hCG level given the fact that she doesn’t know exactly when her last menstrual period was. You also order a peripheral IV so you can send off a basic CBC with diff, BMP, pT/pTT, type & Rh, and provide her with IVFs to get her prepared for her pelvic ultrasound and UA. You give her some Tylenol for her abdominal cramping and keep her NPO otherwise.
She questions you with her eyes intently and says, “What do you think could be going on with my baby? My pregnancy test at home was positive. I just don’t know why I’m having all of this bleeding and pain.”
You gently coax her into the lithotomy position so that you can perform a good transabdominal pelvis scan followed immediately by a transvaginal evaluation of her uterus and adnexa. You insert the intracavitary probe with the indicator pointing anterior towards the patient’s pubic symphysis. You carefully sweep through the patient’s uterus and this is what you see (above).
What do you see on your ultrasound?
What do you need to do now? Conclusion on next page