A community forum shared by EM sonographers of the GWU and Georgetown departments of Emergency Medicine

Mar 5, 2009 0

Abdominal pain: “My pregnancy test was negative”

A 25 year old woman presented with a chief complaint of abdominal pain. She was seen for the same complaint one week ago, but reports worsening pain. Her past medical history is unremarkable, and she takes no medicines and has no allergies.
VS: T 98.9 P136 BP 80/60 RR 16 O2 sat 99% on RA
With these concerning vital signs she is placed in a monitored room and her vital signs are repeated: P 108, BP 96/60. She is given 2L of IVF and blood is drawn for labwork. She is unable to urinate after receiving fluids, but explains that she had a “negative pregnancy test last week” at the office of her OB/GYN doctor. A CT of her abdomen and pelvis is ordered. Sign out is as follows: “Check labs, follow up on results of CT”. The resident caring for the patient noted the vital signs and performed a FAST and transabdominal ultrasound…

Free fluid seen in RUQ

Figure 1: Free fluid seen in RUQ

Free fluid seen in RUQ

Figure 2: Free fluid seen in LUQ

Free fluid seen in pelvis on TV ultrasound

Figure 3: Free fluid seen in pelvis on TV ultrasound


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Figure 3: Grossly positive FAST exam with free fluid in the LUQ


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Figure 4: Free fluid seen around R adnexa

Given these findings, a pregnancy test was performed and found to be positive. OB/GYN was consulted and emergently took the patient to the OR where laparoscopic exploration revealed a tubal pregnancy. The patient underwent salpingectomy and recovered succesfully. In the case of undifferentiated hypotension in a young woman, ectopic pregnancy is high on the differential. A 2008 study published in Academic Emergency Medicine demonstrated a significant correlation between the presence of free fluid in Morrison’s pouch on FAST exam and the need for definitive operative management in the setting of extrauterine pregnancy (1). The average time of the scans in this study was less than five minutes, demonstrating potential to significantly decrease ER to OR time in the setting of an unstable patient requiring operative intervention.

Recommended reading: (1) Moore C, Todd W, O’Brien E, et al. Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy. Academic Emergency Medicine 2008; 14(8):755-758.

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