1. CASE

2. Case HX 39 year old female 39 year old female From PCP for abdominal pain/ spotting From PCP for abdominal pain/ spotting Note from PCP Note from PCP last 2 periods irregular last 2 periods irregular Acute Abdomen Acute Abdomen Possible PID Possible PID G3P2012- ectopic 15 years ago G3P2012- ectopic 15 years ago Menses irregular x 6 mo Menses irregular x 6 mo Denied sex x 2 years Denied sex x 2 years

3. Case HX Pain- 6/10, Pain- 6/10, crampy crampy super pubic super pubic intermittent x 2 days intermittent x 2 days Spotting x 6 days Spotting x 6 days No Urinary Sx No Urinary Sx No n/v/d/c No n/v/d/c No cp/sob No cp/sob

4. Case PX T 97 HR 76 RR 16 BP 133/90 POx 99% T 97 HR 76 RR 16 BP 133/90 POx 99% Well appearing* Well appearing* Abdomen Abdomen soft soft mild midline super pubic tenderness mild midline super pubic tenderness Non distended Non distended normal bowel sounds normal bowel sounds Pelvic exam Pelvic exam No CMT No CMT os closed os closed min dark discharge min dark discharge

5. Case Labs Positive U-Preg! Positive U-Preg! B-quant 17,953 B-quant 17,953 T&S O+ T&S O+ UA +UTI UA +UTI

6. Ultrasound

7. Ultrasound

8. Ultrasound

9. Ultrasound

10. Ultrasound

11. Ultrasound

12. Ultrasound

13. Ultrasound

14. Ultrasound

15. Ultrasound

16. Ultrasound

17. Ultrasound

18. U/S Findings IUP IUP Minimal FF Minimal FF Lt ovary Lt ovary Heterogeneous mass Heterogeneous mass Double desidual sign Double desidual sign Ectopic pregnancy left ovary Ectopic pregnancy left ovary + Prior ectopic. No tubal ligation or IVF No tubal ligation or IVF

19. Encounter conclusion Diagnosis Diagnosis Threatened AB, Corpus Luteal cyst Threatened AB, Corpus Luteal cyst UTI UTI RX: Macrobid & PNV RX: Macrobid & PNV Pt was RH + Pt was RH + No need for Rhogam No need for Rhogam Discharged home with good d/c instructions including need for f/u pelvic u/s and prompt OB f/u, because of ovarian abnormality Discharged home with good d/c instructions including need for f/u pelvic u/s and prompt OB f/u, because of ovarian abnormality Attending spoke to OB Attending spoke to OB

20. 2 nd visit 3 days later 3 days later 97.3 74 18 121/73 100% 97.3 74 18 121/73 100% Pt still w/ abd cramping, more bleeding, and vomiting Pt still w/ abd cramping, more bleeding, and vomiting Scheduled for ADC that day Scheduled for ADC that day ADC showed IUP- and presumed cystic mass in ovary w/ copious FF ADC showed IUP- and presumed cystic mass in ovary w/ copious FF Went to OR for Ex laparoscopy – diagnosis of ruptured ectopic -Heterotopic Pregnancy Went to OR for Ex laparoscopy – diagnosis of ruptured ectopic -Heterotopic Pregnancy

21. Outcome Vitals remained stable Vitals remained stable Hemoglobin remained stable Hemoglobin remained stable Pt did well. Pt did well.

22. Heterotopic Pregnancy Alexis Palley Langsfeld MD

23. Introduction Case report Case report Definition Definition Incidence Incidence ED work up ED work up Differential Diagnosis Differential Diagnosis What can I do not to miss this? What can I do not to miss this? Conclusion Conclusion

24. Heterotopic Pregnancy Definition Co-existent gestations that occur at 2 or more implantation sites.

25. Heterotopic Case study of a 39 year old Women undergoing IVF Case study of a 39 year old Women undergoing IVF Brigham RAD. Brigham RAD. Michael Cooney MD, Mary C Frates MD, Peter M Doubilet MD PhD Michael Cooney MD, Mary C Frates MD, Peter M Doubilet MD PhD

26. Heterotopic pregnancy

27. Heterotopic CRL

28. Heterotopic FHR

30. IUP after treatment of ectopic w/ KCL

31. Heterotopic pregnancy Epidemiology Incidence 1: 30,000 - 1: 100 Incidence 1: 30,000 - 1: 100 As high as 1:100 With fertility treatment ovulation inducers, or IVF. Tal et. al. As high as 1:100 With fertility treatment ovulation inducers, or IVF. Tal et. al. Risk Factors Risk Factors IVF IVF Hormonal fertility treatments Hormonal fertility treatments Tubal ligation Tubal ligation Prior ectopic/anatomic abnormalities/PID/Endometriosis Prior ectopic/anatomic abnormalities/PID/Endometriosis

32. Heterotopic ED Work Up Women of child bearing age w/ belly pain or UG complaint Women of child bearing age w/ belly pain or UG complaint UA/U-PREG UA/U-PREG VITALS are vital! VITALS are vital! Blood work? Blood work? If bleeding check T&S If bleeding check T&S B-Quant B-Quant Hgb Hgb Fluids-clinical judgment Fluids-clinical judgment Pelvic Pelvic Cx Cx Wet mount Wet mount Ultrasound Ultrasound OB consult / definitive treatment OB consult / definitive treatment

33. Heterotopic Ultrasound Findings IUP IUP Thick walled, fluid filled structure Thick walled, fluid filled structure May show dd sign May show dd sign May have fetus or clot within it May have fetus or clot within it Can be anywhere Can be anywhere In ovary In ovary In tube In tube In adenexa In adenexa Adjacent to any structure Adjacent to any structure

34. Heterotopic treatment/outcomes Surgical removal Surgical removal Oophorectomy Oophorectomy Salpingectomy Salpingectomy Hysterectomy Hysterectomy Methotrexate Methotrexate Embolization if necessary for hemorrhage Embolization if necessary for hemorrhage Kcl injection into ectopic embryo under u/s guidance Kcl injection into ectopic embryo under u/s guidance

35. Differential Diagnosis Ectopic Pregnancy Ectopic Pregnancy Follicular cyst- 1 st half cycle Follicular cyst- 1 st half cycle Corpus Luteal Cyst Corpus Luteal Cyst IUP IUP Appendicitis Appendicitis UTI UTI PID PID

36. Ectopic Pregnancy 13% of first trimester pregnancies presenting to the ED with Pain and/or vaginal bleeding have an ectopic pregnancy. 13% of first trimester pregnancies presenting to the ED with Pain and/or vaginal bleeding have an ectopic pregnancy. Ectopic Pregnancy: Prospective Study With Improved Diagnostic Accuracy Ectopic Pregnancy: Prospective Study With Improved Diagnostic Accuracy BC Kaplan, Ann Emerg Med 1996;28:10-17

37. Ectopic Pregnancy 2% of all pregnancies 2% of all pregnancies 6 fold inc since 1970 6 fold inc since 1970 9% of pregnancy related deaths 9% of pregnancy related deaths Risk Factors Risk Factors PID PID Prior ectopic Prior ectopic Tubal Ligation Tubal Ligation Endometriosis Endometriosis Infertility treatments Infertility treatments Anatomic abnormalities Anatomic abnormalities SMOKING SMOKING Only 3% are ovarian. Bouyer, J Only 3% are ovarian. Bouyer, J

38. Ectopic Pregnancy

39. Corpus Luteal Cyst Functional Cyst Functional Cyst After ovulation, the ruptured follicle develops into the corpus luteum After ovulation, the ruptured follicle develops into the corpus luteum Corpus luteum makes progesterone in anticipation for supporting a fertilized egg Corpus luteum makes progesterone in anticipation for supporting a fertilized egg With no fertilization, the CL withers, progesterone falls, and menses occur With no fertilization, the CL withers, progesterone falls, and menses occur A corpus luteal cyst develops when the CL does not whither, and instead fills w/ fluid A corpus luteal cyst develops when the CL does not whither, and instead fills w/ fluid

40. Corpus Leutial Cyst U/S In the ovary In the ovary Thin Walled Thin Walled often irregular often irregular Large Large Fluid filled Fluid filled Should not show dd sign Should not show dd sign No yolk sac!- but may have clot or septum No yolk sac!- but may have clot or septum

41. Corpus Luteal Cyst

42. How Do I Not Miss My Heterotopic Evaluate for risk factors Evaluate for risk factors Clinical picture Clinical picture Is your pt stable Is your pt stable HR HR BP BP Check a u-preg in all women of reproductive age with belly pain or u/g complaints Check a u-preg in all women of reproductive age with belly pain or u/g complaints LOOK with the ultrasound LOOK with the ultrasound View the adenexa View the adenexa Look for free fluid Look for free fluid B-Quant may be helpful B-Quant may be helpful If you are not comfortable w/ your scan – get help If you are not comfortable w/ your scan – get help Keep looking for it Keep looking for it Good discharge instructions Good discharge instructions

43. Conclusion Heterotopic pregnancies are more common than they once were Heterotopic pregnancies are more common than they once were Pt with risk factors need to be taken seriously Pt with risk factors need to be taken seriously Check the adenexa Check the adenexa Review your differential Review your differential Give good discharge instructions Give good discharge instructions If you are not comfortable w/ your scan – get help! If you are not comfortable w/ your scan – get help!