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Case of the Month 06/10

This 33-year-old female presented to the ED after two days of vaginal spotting. She had found out she was pregnant 2 days prior and had noted severe lower abdominal pain the day before which had since resolved. On exam, she was hemodynamically stable with tenderness to the left lower quadrant and a small amount of vaginal bleeding.

Question 1: What's wrong with these pictures?

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Answer 1:

This is an interstitial pregnancy. In the US, this term is often used interchangeably with the term cornual pregnancy although technically, they are slightly different. (In both, the fetus is located in the part of the fallopian tube entering the uterus, but a cornual ectopic occurs in patients with bicornuate uterus whereas an interstitial ectopic occurs in patients with an anatomically normal uterus.) Note in the first image that the fetus is located off to the side of the uterus and that in the second two images that the fetus is actually outside of the uterus.

Question 2: Why is this such a bad diagnosis to miss?

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Answer 2:

Because there is more room for the fetus to develop in the interstitial ectopic, rupture may not occur until a later gestation age than a typical tubal ectopic pregnancy. This delayed rupture and result in massive hemorrhage with a reported mortality rate up to 2 percent. This patient was diagnosed in the ED and underwent a salpingectomy/ectopic resection that evening. She was discharged in stable condition 4 days later.