A 33-year-old woman presents to the emergency depament complaining of nausea and vomiting. She states that she has been having significant nausea that has been worsening over the past 2 weeks. Over the past 2 days, she has had 2 episodes of vomiting. She also notes increased fatigue. She has no abdominal pain or vaginal bleeding. She has no other complaints. Her past medical history is significant for occasional migraine headaches. She has never had surgery. She takes acetaminophen as needed for headache, and has no known drug allergies. She works as a lawyer at a local firm and lives with her husband for three years. She has no family history of cancer or hea disease. Her vital signs are stable. Examination is significant for a bluish-appearing cervix on speculum examination. The remainder of the examination, including the abdominal examination, is benign. Laboratory evaluation shows: Urine hCG: positive Leukocytes: 9,000/mm3 Hematocrit: 41% Platelets: 250,000/mm3 Pelvic ultrasound demonstrates a gestational sac with yolk sac and fetal pole surrounded by myometrium. There is a hea rate of 154 beats per minute. Which of the following is the MOST likely diagnosis?
This patient's presentation, exam findings, and studies are all consistent with a diagnosis of intrauterine pregnancy. First, her presenting complaints of nausea, vomiting, and fatigue are consistent with a first trimester pregnancy. Approximately 80% of pregnant women experience some nausea during the pregnancy, especially in the first trimester. This nausea is most commonly called "morning sickness" but it can occur at any time during the day. Fatigue is also a common first trimester complaint. On examination she has a bluish-appearing cervix. This is called "Chadwick's sign" and it is another clue that she is pregnant. Most definitively, though, she has a positive urine pregnancy test. With this positive test, the diagnosis is narrowed to intrauterine pregnancy, ectopic pregnancy, or spontaneous aboion, with mole also being a consideration. The ultrasound that demonstrates an intrauterine pregnancy fully establishes the diagnosis. Note: Appendicitis represents an infection of the appendix. Patients with appendicitis most commonly present with symptoms and signs of infection, including abdominal pain, fever and chills, abdominal tenderness, elevated temperature, and leukocytosis. A patient with a complete hydatidiform mole will not have an intrauterine pregnancy with a fetal hea rate visualized on ultrasound examination. A complete mole often appears as a "snowstorm" pattern on pelvic ultrasound. It is essential to "think ectopic!" whenever a woman of childbearing age presents for medical attention. In fact, this sign ("think ectopic!") and other such similar signs can be seen in many emergency rooms. However, patients with ectopic pregnancy usually complain of abdominal pain or vaginal bleeding. On examination, they will often have abdominal and adnexal tenderness. Pelvic ultrasound will show no intrauterine pregnancy. This patient, with a gestational sac, yolk sac, and fetus seen surrounded by myometrium (that is, within the uterus) can be diagnosed with an intrauterine pregnancy. Ref: Fritz D.A. (2011). Chapter 6. Emergency Bedside Ultrasound. In R.L. Humphries, C. Stone (Eds), CURRENT Diagnosis & Treatment Emergency Medicine, 7e.
Appendicitis
Complete hydatidiform mole
Ectopic pregnancy
Intrauterine pregnancy