Expect the Unexpected

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When it rains, it pours. You and your overnight team of residents have just finished some of the most challenging tasks in emergency medicine. Through a translator, you had to tell the lady in room two that her abdominal CT shows a pancreatic mass that will “need further work-up.” You were asked by family members to reverse the DNR and aggressively resuscitate an elderly hospice patient in dire straits, and, to top it off, the two-year-old hit-and-run you just saw in the trauma bay had non-survivable injuries. You are definitely looking forward to the traditional early morning debriefing at the local breakfast diner after the black cloud clears.

You breathe a small sigh of relief when your senior resident begins presenting his next case to you. The patient is a 17-year-old G1P0 who found out she was pregnant via a home pregnancy test last month. She hasn’t seen a doctor about her “condition” yet. She presents to the ED at 6 AM because she has been vomiting all night and can’t sleep. She’s been feeling nauseated all week long, and now notes that things are definitely getting worse. She denies any other symptoms such as bleeding, pain or fever. Other than looking a bit peaked, your resident feels that she’s pretty healthy and stable. She’s a bit tachycardic with a pulse of 108, but her vital signs are otherwise normal. Your resident ordered for a peripheral IV to be placed, a rainbow of tubes to be drawn and held, a liter of normal saline and a dose of ondansetron. He ordered a urinalysis off the straight catheterization he performed during her pelvic exam. Now, all he needs is for you to help him with the endovaginal ultrasound he is preparing to perform at the bedside.

As your resident is setting up the machine and the archiving system, you silently thank the powers that be for giving you at least one straightforward case for the night. The patient and her boyfriend are pleasant and thankful, and your resident is about to complete the final pelvic ultrasound he needs to fulfill his credentialing requirements. He carefully explains to them that he is going to perform a limited study at this time and that at some point a more comprehensive scan will need to be ordered through the radiology department.

You have your resident start with a transabdominal scan with the 3.5 MHz curvilinear probe so you can map out the pelvic structures and get a sense of what lies ahead. After obtaining a few images, you exchange a subtle glance with your resident and see that he has his best poker face on, too. After taking a quick peek at the hepatorenal space, your resident moves on to the endovaginal scan using a 5-8MHz intracavitary transducer and obtains the following images:

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What do you see on the transverse and longitudinal views of the uterus? What do you do next?

After your resident scans through the entire uterus and cervix, he turns his attention to both adnexa. Satisfied with his thorough views of the pelvis, he tells the patient that he is going to order a comprehensive ultrasound via radiology to obtain a bit more information about her pregnancy. He informs them that he will come back to check on her and that he will let her know as soon as possible what her test results are.

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“I can’t believe our bad luck tonight!” your resident says, wide eyed with disbelief. “A molar pregnancy?!” You review the images with your resident outside of the room and highlight the “cluster of grapes” appearance noted on the scan. There are no theca lutein cysts in her ovaries and she has good flow on color Doppler bilaterally. Your team promptly orders a serum ß-hCG level, CBC, CMP, TSH, free T4, and a coagulation panel off of the blood that was drawn earlier. You also order a CXR to evaluate for metastases. As expected, the patient’s ß-hCG level is remarkably elevated at 310,000 mIU/mL. Fortunately, the remainder of her lab tests and CXR are unremarkable.

Your resident consults Ob/Gyn for admission and D&E, and you proudly watch your senior resident deliver the unfortunate news with sensitivity and empathy. Before you know it, the end of your shift arrives, and you and your hard-working overnight team step out into the sunshine – a new day and a fresh start.

Editor’s Note: Gestational Trophoblastic Disease, By the Numbers
  • GTD occurs in about 1 per 1700 U.S. pregnancies, but is more common in other parts of the world (Japan).
  • Most GTD is benign hydatidiform mole (80%), but more malignant forms of GTD include invasive mole (12-15%) and choriocarcinoma (5-8%) which can metastasize to the lung, liver, and brain — and is very sensitive to chemotherapy GTD is often associated with a markedly elevated ß-hCG.
  • The typical patient presents with nausea, vomiting, and vaginal bleeding
  • Qualitative hCG testing may be negative
  • Molar pregnancy can coexist with ectopic pregnancy
  • Molar pregnancy related thyroid storm has been described and should be considered in any pregnancy female with suspicion for GTD and symptoms compatible with thyrotoxicosis

Pearls & Pitfalls for Pelvic Ultrasound

1 Incorporate bedside ultrasound into your clinical practice. It can provide you with fast, reliable data that can help guide and expedite your management plans.

2 When performing a pelvic ultrasound, always begin with a transabdominal scan to obtain a general overview of your patient’s pelvic anatomy. Use a 3-5 MHz curvilinear or phased array transducer for transabdominal imaging. Remember that a full urinary bladder provides a great acoustic window for the transabdominal scan. Don’t forget to check Morrison’s pouch for free fluid whenever there is concern for a ruptured ectopic pregnancy.

3 Have your patient empty her bladder prior to the endovaginal portion of the scan.

4 Apply a copious amount of gel over the intracavitary transducer (ICT) and then cover the probe and gel with a transducer sheath or condom. Apply another layer of bacteriostatic surgical gel on the outside of the transducer sheath at the tip of the probe.

5 Insert and advance the transducer with the indicator marker poi
nting anteriorly towards the patient’s pubic symphysis. Alternatively, you may let the patient insert the probe herself as this method is often less uncomfortable.

6 Scan through the entire pelvis in both the transverse and longitudinal planes. Don’t prematurely terminate your scan just because you find the answer you are looking for early on. Unexpected findings may lie in the periphery.

7 Molar pregnancies will appear as a “cluster of grapes” on high-resolution bedside ultrasonography. The complex echoic intrauterine mass will be speckled with round, hypoechoic cystic chorionic villi. The old “snowstorm appearance” of molar pregnancies refers to the images laden with artifact seen with older, low-resolution ultrasound machines.

8 Note that molar pregnancies are associated with theca lutein cysts in the ovaries. Make sure you evaluate both adnexa for the presence or absence of masses and flow.

9 Practice Makes Perfect: With bedside ultrasound, there is no substitute for experience. The more scans you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is. You can find many ultrasound images in the ultrasound section of epmonthly.com.

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