Obstetrical Emergency: An Unusual Case of an Ectopic Pregnancy

Abstract

A 21-year-old African American woman presented to the emergency department with a 3-week history of heavy vaginal bleeding; she had experienced varying amounts of bleeding but never needed more than a pad per hour. She was known to be less than 12 weeks pregnant but was unsure of the date of her last menstrual period. She was gravida 3 and parity 2, with a spontaneous vaginal delivery approximately 5 years earlier and an “abdominal” (presumed ectopic) pregnancy removed by laparotomic surgery 5 months earlier at an outside institution. Other medical history included hypertension, depression, bipolar disorder, and surgery for a “hernia repair.” All laboratory values were within normal limits, and her human chorionic gonadotropin level was 8009 mIU/mL. Differential considerations at this time were threatened or spontaneous abortion and recurrence of ectopic pregnancy. Upon transvaginal sonography, a bicornuate uterus was identified (Figure ​(Figure11). No adnexal abnormalities were appreciated. Within the right cornua, a gestational sac, yolk sac, and fetal pole were identified and diagnosed as a cornual ectopic pregnancy (Figure ​(Figure22). Fetal heart tones measured approximately 120 beats per minute. No appreciable myometrium surrounded the gestational sac (Figures ​(Figures33 and ​and44). The left cornua demonstrated a thick endometrium, most likely related to hyperestrogenemia from a pregnant state, without any other abnormality. Figure 1 Transvaginal ultrasound demonstrates two endometrial horns compatible with a bicornuate uterus. Figure 2 Transvaginal ultrasound demonstrates an ectopically located gestational sac in the right cornua with surrounding hypervascularity. Figure 3 Transvaginal ultrasound of the uterus and adjacent iliac vessels demonstrates no significant myometrium surrounding the gestational sac. Figure 4 Transvaginal ultrasound of the uterus with ectopically located gestational sac demonstrating a fetal pole and yolk sac. DIAGNOSIS: Cornual ectopic pregnancy.