1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Stephanie A Bernard Affiliation: Penn State University

2. MedPix No: 8346 - History Pt Demographics: Age = 29 y.o. Gender = woman Prior history of a spontaneous AB and a ectopic (side not known) presenting to an ER in Alabama while driving to Virginia secondary to pelvic pain and +home pregnancy kit. U/S performed at that time reported as Spontaneous AB.Patient completed here road trip to Virginia and presented to the hospital with persistent pelvic pain. Downloaded by (-1)

3. MedPix No: 8346 - EXAM & LABS hCG 2100 (3rd International Standard)Diffuse abdominal pain.Preliminary u/s by ER physician unable to identify an IUP.

4. Ruptured Ectopic Pregnancy Transabdominal images demonstrate a large heterogeneous mass filling the pelvis. The normal architecture of the uterus is difficult to discern. The ovaries are also unable to be identified. - - Transvaginal images demonstrate a similar appearance with no internal blood flow within this mass and a seperate normal uterus without IUP seen eccentrically displaced anteriorly and to the left within the pelvis. Downloaded by (-1)

5. Ruptured Ectopic Pregnancy Transabdominal images demonstrate a large heterogeneous mass filling the pelvis. The normal architecture of the uterus is difficult to discern. The ovaries are also unable to be identified. - - Transvaginal images demonstrate a similar appearance with no internal blood flow within this mass and a seperate normal uterus without IUP seen eccentrically displaced anteriorly and to the left within the pelvis. Downloaded by (-1)

6. Ruptured Ectopic Pregnancy Transabdominal images demonstrate a large heterogeneous mass filling the pelvis. The normal architecture of the uterus is difficult to discern. The ovaries are also unable to be identified. - - Transvaginal images demonstrate a similar appearance with no internal blood flow within this mass and a seperate normal uterus without IUP seen eccentrically displaced anteriorly and to the left within the pelvis. Downloaded by (-1)

7. Ruptured Ectopic Pregnancy Transabdominal images demonstrate a large heterogeneous mass filling the pelvis. The normal architecture of the uterus is difficult to discern. The ovaries are also unable to be identified. - - Transvaginal images demonstrate a similar appearance with no internal blood flow within this mass and a seperate normal uterus without IUP seen eccentrically displaced anteriorly and to the left within the pelvis. Downloaded by (-1)

8. Ruptured Ectopic Pregnancy The actual uterus Downloaded by (-1)

9. Ruptured Ectopic Pregnancy The actual uterus Downloaded by (-1)

10. FINDINGS Transabdominal images demonstrate a large heterogeneous mass filling the pelvis. The normal architecture of the uterus is difficult to discern. The ovaries are also unable to be identified.Transvaginal images demonstrate a similar appearance with no internal blood flow within this mass and a seperate normal uterus without IUP seen eccentrically displaced anteriorly and to the left within the pelvis.

11. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Fibroid Uterus with Missed AB - Hematoma / Ruptured ectopic - Hematometrosis - Complex pelvic mass - - Ovarian tumor - Complex ovarian cyst from hemorrhage / Endometriosis - Soft tissue tumor - Sarcoma

12. Diagnosis: Ruptured Ectopic Pregnancy Dx Confirmed by: Surgical Removal

13. DISCUSSION With very large abnormalities, it is sometimes difficult to see the forest through the trees. For this case it required going from transabdominal to transvaginal and back to transabdominal for the tech to recognize what was being seen. This patient was very fortunate that the hematoma stopped further bleeding. No free flowing blood/fluid was identified in the Morrison*s pouch.