A 36 year-old-female with no significant PMH presented to our ED with LLQ abdominal pain. The pain started 4 days prior to arrival. An hour prior to being seen in the ED, the pain got acutely worse. The patient’s LMP was 23 days prior to her visit to the ED. She denied vaginal bleeding, abnormal vaginal discharge, fever, nausea, vomiting, constipation, and diarrhea.

Initial VS: BP 123/86 , HR 86, T 36.5 °C (97.7 °F), RR 19, SpO2 100% on RA

Physical exam revealed a woman who appeared quite uncomfortable and had exquisite tenderness in the LLQ of the abdomen.

The initial concern was for ovarian torsion, ruptured ovarian cyst, or ectopic pregnancy. Initial BSUS was preformed on arrival to look for free fluid in the pelvis. No free fluid was appreciated, however, this was seen:

This is her left ovary with a large cyst. Given that her pain was left-sided and the ovary was slightly enlarged, the providers were concerned that her pain could be from torsion.

CBC, chemistry panel, UA, UPT, and blood type and screen were all ordered given a high suspicion that something was wrong. She was given a fluid bolus and pain medications. A formal transvaginal ultrasound was also ordered.

Shortly after her arrival, she got up from her bed to go give a urine sample and became very lightheaded. She was helped back into bed and a RUQ ultrasound was performed. See the images below:

This clip shows a large amount of free fluid in the right upper quadrant. This finding made a diagnosis of ectopic pregnancy much more likely.

In pregnant females, the finding of hepatorenal free makes the likelihood of ectopic pregnancy nearly 100%. This patient was not known to be pregnant and her UPT had not been completed yet, but the diagnosis of ectopic pregnancy still seemed most likely.

OB/gyn was consulted emergently and urine sample was obtained for UPT via catheter placement.

While awaiting the results of the UPT, transvaginal BSUS was preformed. Here is an image of the patient’s uterus:

You can see that the uterus is empty, but there is a large amount of clot surrounding the uterus. There is a small amount of blood that is not clotted seen near the cervix. In patients that are bleeding rapidly, clotting can occur and the classic anechoic free fluid might not be seen. Here is a picture highlighting what is seen in the clip:

The uterus is outlined in red. Clot surrounds the entire uterus. In retrospect, this clot was probably present on the initial scan but overlooked. Further imaging was performed without obvious identification of an ectopic pregnancy.

Her UPT came back positive, and she was taken to the OR with OB/gyn immediately.

Intraoperatively, she was found to have a left-sided ectopic and underwent a salpingectomy. 3L of blood was evacuated from the patient’s abdomen.

She did well and was discharged later that day.

Bottom Line: In pregnant women, free fluid in the hepatorenal space is highly suggestive of ectopic pregnancy. We would recommend obtaining a hepatorenal view on all patients presenting to the ED with suspected ectopic.