A 31-year-old woman comes to the emergency depament because of abdominal pain and vaginal spotting. She states that the pain began 2 days ago and has been worsening since. The spotting occurred this morning. Her last menstrual period was 6 weeks ago. She has no medical problems. She takes no medications and has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 90/50 mm Hg, pulse is 110/minute, and respirations are 14/minute. Abdominal examination reveals significant lower abdominal tenderness. Speculum examination shows scant blood in the vagina with a closed cervical os. Bimanual examination demonstrates significant left adnexal tenderness. Urine hCG is positive. Serum hCG is 5,000 mIU/mL. Pelvic ultrasound shows a normal uterus with a left adnexal mass surrounded by free fluid. Which of the following is the most likely diagnosis?
This patient has a presentation that is most consistent with ectopic pregnancy. The most common presenting symptoms of patients with ectopic pregnancy are abdominal or pelvic pain and vaginal bleeding. However, many patients have ectopic pregnancies and are asymptomatic until they are discovered incidentally on ultrasound or until they rupture. Examination of a patient with ectopic pregnancy often demonstrates tenderness on the side of the ectopic pregnancy. Occasionally, a mass can be appreciated on that side. The keys to the diagnosis of ectopic pregnancy are the serum hCG value and the ultrasound. This patient has a serum hCG level of 5,000 mIU/mL. At this hCG level, a pregnancy would be visualized if it were, in fact, in the uterus. This patient has an ultrasound showing nothing in the uterus with a mass in the left adnexa. This constellation of symptoms and findings are most consistent with the diagnosis of ectopic pregnancy. Appendicitis can also present with abdominal pain. However, the pain and findings are most often on the right side of the patient's abdomen and this patient has a mass and tenderness on the left side. Fuhermore, vaginal bleeding and elevated hCG levels are not associated with appendicitis. Occasionally, a patient with ovarian cancer will have an hCG-secreting tumor. However, when a woman of childbearing age presents with abdominal pain and vaginal spotting and has a positive hCG value, the diagnosis is almost always pregnancy-related (either ectopic pregnancy, intrauterine pregnancy, or spontaneous aboion) and not ovarian cancer. Pelvic inflammatory disease is rare, but does sometime occur during pregnancy. This patient, however, has findings more consistent with ectopic pregnancy than pelvic inflammatory disease.
Appendicitis
Ectopic pregnancy
Ovarian cancer
Pelvic inflammatory disease