A Second Trimester Abdominal Ectopic Pregnancy Visualised Using Standard and Handheld Point-of-Care Ultrasound: A Case Report.

We describe a 27‐year‐old woman presenting with abdominal pain at 13 + 1 weeks gestation. She had a history of low ovarian reserve, subfertility, and a multi‐fibroid uterus (57 × 47 mm fundal subserosal, 38 × 33 mm posterior intramural, 31 × 25 mm posterior subserosal, 28 × 28 mm anterior subserosal, plus multiple smaller fibroids measuring up to 16 mm in size, uterine volume 306 cc). She spontaneously conceived after 3 years of trying. She had no known imaging features of endometriosis. She had a normal hormone profile but a low anti‐Müllerian hormone (AMH) of 2.4 pmol/L. She attended for a routine dating scan with a history of left lower quadrant pain. On examination, her abdomen was soft and diffusely tender in the suprapubic region. Informed, written consent was obtained from the patient for publication of this case report. No ethical approval was required. The initial dating TAUS (Figure  1A,B ) was reported as a probable intrauterine pregnancy (IUP). A combined screening test (CST) gave a 1 in 2 chance for trisomy 21 and a 1 in 4 chance for trisomies 13 and 18 (Figure  2 ). Ultrasound images. (A, B) Initial departmental ultrasound images demonstrating a fetus with a crown‐rump length (CRL) of 69 mm and nuchal translucency of 3.1 mm. The fetal anatomy and amniotic fluid volume was described as normal. The placenta was described as posterior. (C, D) Second ultrasound within early pregnancy unit scan demonstrating empty uterine cavity both transvaginally and transabdominally. Combined screening test results. Repeat TA and TV US by a level 3 nurse sonographer (GE Voluson E10) (Figure  2C,D ) demonstrated a multi‐fibroid uterus and an extrauterine pregnancy with an empty uterine cavity and visible ‘endometrial stripe’. The operating surgeon (EFSUMB level 3) used a handheld ultrasound (GE Voluson Air) to facilitate pre‐operative counselling in the ward setting. This allowed for contextualisation of the rationale for surgery and planned surgical approach alongside ‘real time’ images displayed on a mobile phone. The handheld images (Figure  3 ) demonstrated an empty uterine cavity and an extrauterine pregnancy in the left adnexa with no visible continuity with the cervix. The relationship to the ipsilateral ovary could not be assessed. Same‐day MRI showed a left adnexal EP which was presumed to be within the fallopian tube (Figure  4 ). Blood test results are summarised in Table  1 . Point of care ultrasound images. Sagittal (A) and transverse (B) images of uterus (purple) and gestation sac (blue) on point of care ultrasound. MRI images. (A, B) Coronal view of multi‐fibroid uterus (pink arrow) and pregnancy sac (blue arrow). (C) Axial view of uterus with left sided gestation sac visible. MRI showing the left adnexal pregnancy. The left ovary was seen separately. There was peripheral haemorrhage surrounding the gestation sac with a moderate intraperitoneal haematoma and free fluid within the perihepatic space and paracolic gutters. Blood results. The patient was informed of the findings and surgical management was recommended. A consultant‐led multi‐disciplinary team (MDT) including gynaecologists, haematologists, and radiologists managed this case. In our institution complex gynaecological surgery is supported by the gynae oncology service with access to general surgeons as required. Current UK practice does not warrant abortion consent to be completed for ectopic pregnancy, and as such this was not deemed legally required in this case. A diagnostic laparoscopy via Palmer's point entry was initially performed. Direct visualisation of the pregnancy noted it to be enveloped by overlying omentum. Extensive perihepatic and abdominal adhesions were noted. The omentum was dissected to reveal the gestational sac with a live fetus. Cessation of cord pulsation was performed with a handheld thermal device (Thunderbeat, Olympus Medical Systems). Due to ongoing active resuscitative measures, a decision to convert to laparotomy was made for life‐saving purposes. Active haemorrhage was noted from feeding neovascularised vasculature associated with the AEP. Both small and large bowel serosa had adherent trophoblastic tissue overlying (Figure  5 ). The fimbrial fallopian tube was grossly inflamed with haemosiderin and haemorrhagic clots adjacent. Despite attempts to salvage the ovary, the bleeding was such that an adnexectomy was performed due to ongoing transfusion requirements. Trophoblast was excised and a left salpingo‐oophorectomy was performed. There was no macroscopic evidence of endometriosis. The total blood loss was 2000 mL and the patient was admitted to the intensive care unit (ICU) for one night. Total blood products administered were three units of packed red blood cells and two units of fresh frozen plasma. Intraoperative images showing trophoblast and haemosiderin deposits within the intraabdominal cavity, including involvement of bowel serosa (white arrows). The patient was discharged on day 9 post‐operatively, after recovery from post‐operative ileus. She completed outpatient follow‐up via early pregnancy unit with serial serum beta human chorionic gonadotrophin (BhCG) levels which declined to < 15 IU/L after 3 weeks. She was re‐referred to fertility services and for appropriate psychological support. The histology confirmed a para‐ovarian abdominal ectopic pregnancy. There were decidualised cells within the omentum. The Fallopian tube had significant salpingitis and partially infarcted chorionic villi showing the location of initial implantation, with trophoblastic cells infiltrating the surrounding tissue, and possible features of prior endometriosis. The left ovary showed a corpus luteum, congestion, and granulation tissue on its surface. “I never expected to lose my baby, that was a big thing for me. I had been trying for three years. I did not know what to do or what to decide. All the team has supported me and made me feel better… I have pain but I am getting through it.”

Nina Cooper: conceptualization, writing – original draft, methodology, investigation, writing – review and editing. Alex Novak: writing – original draft. Georgina Gould: writing – original draft. Shaun Haran: writing – original draft. Maeve Tuomey: data curation. Maya Al‐Memar: data curation, writing – review and editing, supervision. Catriona Stalder: data curation. Tom Bourne: writing – review and editing, supervision. Joseph Yazbek: writing – review and editing, supervision, investigation, data curation, conceptualization.

Point of care ultrasound findings have been shown to accurately correlate with standard TVUS findings in early pregnancy and have a role as a screening tool to signpost to further imaging [ 5 , 6 ]. This case demonstrates that an AEP can be classified as extrauterine using a transabdominal approach with a handheld ultrasound device. As far as the authors are aware, this is the first case to demonstrate an AEP with this modality. Comparing the image quality (Figure  1 vs.  3 ), handheld US provides lower resolution images but clearly demonstrates that the pregnancy is separate from the cavity. Similarly, handheld ultrasound has been shown to confidently identify pregnancy location in an unselected early pregnancy population ( k  = 0.785, substantial agreement) [ 5 ]. This supports the argument that handheld POCUS has the potential to provide life‐saving diagnostics in the emergency setting where a patient cannot be transferred to a scanning department, as well as in the low‐income setting where standard ultrasound may not be accessible [ 7 ]. There are cases in the literature of AEPs which were unrecognised as extrauterine due to the placenta implanting exclusively on the uterine serosa, in some instances being mistaken for an intrauterine pregnancy associated with a uterine anomaly. In some cases, pregnancies have progressed to a viable gestation or even term, and were subsequently identified as abdominal at delivery [ 8 , 9 ]. Like other cases, where implantation is not exclusively uterine, this case demonstrated infiltration of trophoblast onto the surrounding bowel or omentum. The literature suggests such cases are at greater risk of complication [ 10 ]. Implementing ultrasound in the low resource setting is not just limited by the physical presence of machines, but also the training, maintenance, and infrastructure required to safely provide it. Currently, only 1/3 of women in low‐income settings have access to ultrasound [ 11 , 12 ]. POCUS using smaller hand‐held devices has the potential to improve access; however, the technology still relies on a trained provider. Education is important to facilitate the safe roll‐out of these devices. In the low resource setting, surgery may need to be life‐saving rather than organ‐saving. The unpredictable nature of these pregnancies warrants urgent consideration of a surgical approach with a low threshold to consider life‐saving methods for haemorrhage control [ 13 ]. A case series of 163 AEPs showed a maternal mortality of 12% and a perinatal mortality of 72% [ 14 ]. In low resource settings, AEP should be suspected where patients present with an acute abdomen, painful or absent fetal movements, or abdominal pain in the absence of a confirmed IUP, regardless of gestation. Handheld ultrasound is a useful immediate adjunct to physical examination without the need for transfer to an imaging department. Although MRI confirmed an extrauterine pregnancy, the imaging report of a tubal ectopic pregnancy did not correlate with surgical findings. It is, however, possible that this was a secondary abdominal ectopic pregnancy which initially did implant within the tube. Implantation within the ovary was less likely given the histological findings of granulation tissue only on the ovary's surface. Confident mapping of the anatomical relationship of the EP to the abdominal viscera allows for early and prompt pre‐operative liaison with other specialities [ 15 ]. Two separate operators using standard and handheld ultrasound were able to identify an extrauterine pregnancy but could not identify the implantation site. Given its lateral position to the uterus, the EP was suspected to be tubal or ovarian. In cases where the patient is haemodynamically stable, point of care diagnostics may prompt transfer to a specialist unit to facilitate an organ‐sparing and/or fertility‐sparing approach. As a minimum, provision of adequate access to emergency blood products and critical care input should be available. We strongly recommend that all cases have pathways in place for the implementation of an emergency MDT. In this specific case, the combined screening test showed an increased chance of all trisomy 13, 18, and 21 (Figure  2 ). Pregnancy associated plasma protein‐A (PAPP‐A) is a placenta‐derived glycoprotein produced by the trophoblast cells, which typically rises gradually in early pregnancy in a normally‐sited IUP. It was extremely low at 0.06 MoM. In the context of an AEP, a low PAPP‐A may support this as a potential differential diagnosis where cross‐sectional imaging is not readily available [ 16 ]. The psychological impact of an EP should not be underestimated. Using handheld ultrasound, we could counsel the patient in a ward setting with real‐time images. A prospective study of 186 women experiencing early pregnancy loss shows many women fulfil the diagnostic criteria for post‐traumatic stress disorder and moderate–severe anxiety [ 17 ]. In this case, the patient reported that the impact of the loss of a wanted pregnancy was greater than the physical sequelae endured.

AEP remains a rare diagnosis with significant maternal mortality from life‐threatening haemorrhage. Multidisciplinary working with peri‐operative imaging is key to prompt diagnosis and reducing the risk of maternal death. Ultrasound provision is globally imperative to site a pregnancy, ideally in the first trimester where management of EP is less surgically complex. POCUS with handheld devices may make this more achievable.

Abdominal ectopic pregnancy (AEP) describes implantation of a pregnancy within the abdominal cavity, which may be primary (implantation directly outside of the abdomen) or secondary (implantation after tubal rupture) [ 1 ]. Due to its rarity, the exact incidence is uncertain but is estimated at 1%–2% of all EPs [ 2 ]. Early AEP is classified as those identified prior to 20 weeks gestation. The mean gestation at diagnosis is typically 10 + 0 weeks, most are found in the uterovesical or rectouterine pouches or overlying the uterine serosa [ 3 ]. Most cases (87.9%) are managed surgically and are associated with major haemorrhage [ 3 ]. The mortality rate is 7.7 times higher than that of tubal ectopic pregnancy (EP) [ 4 ]. Prompt identification can mean the difference between life and death, especially where access to imaging is limited. Handheld point of care ultrasound (POCUS) may offer an immediate diagnosis; however, the use of POCUS in AEP has not yet been explored.

GE Healthcare loaned the Vscan Air device to the department via author T.B.; however, we no longer have access to the device. GE Healthcare had no involvement in the study design, data collection, analysis, manuscript preparation, or decision to publish this report. The authors declare no financial or commercial conflicts of interest related to this work.