Use Of Point-Of-Care Ultrasound To Evaluate For Ruptured Ovarian Cyst In Pregnant Patients

Introduction: Rupture of an ovarian cyst can commonly present in women of reproductive age presenting to the emergency department (ED) with abdominal pain.
Although it is usually a self-limiting physiological process, excessive hemorrhage or torsion can require surgical intervention.
When a pregnant patient presents with a symptomatic adnexal mass or hemorrhage early in pregnancy, an ectopic pregnancy must be ruled out due to its potentially lethal outcome.
The most common pregnancy-associated adnexal masses are functional, corpus luteum cysts.
Emergency physicians can combine point-of-care ultrasound along with the patient’s clinical presentation to rapidly assess the presence of pelvic free fluid for a more definitive diagnosis.
Ultrasound has high sensitivity and specificity for characterizing pelvic masses; making it an ideal first-line diagnostic tool.
This case demonstrates the rapid identification of a ruptured ovarian cyst in a pregnant patient who was being considered for a ruptured ectopic pregnancy.

Case Description: A 32-year-old Amish woman (G6P5005) presented to the regional emergency department with severe abdominal and pelvic pain with an estimated gestational age of 7 weeks by the last menstrual period (LMP).
She was in acute distress with a BP in the 90s/40s, a RR of 16, and a hemoglobin of 9.8.
The abdominal exam revealed peritoneal signs. The cardiac exam revealed RRR and no murmurs. Lungs were clear bilaterally to auscultation. Extremities showed no edema or perfusion abnormalities.
With a positive urine test, a FAST exam was done and revealed a large amount of suspected hemoperitoneum in the pelvis that extended to the liver. The patient was counseled on a possible ectopic pregnancy with hemoperitoneum and was admitted for a laparotomy.
Laboratory studies before surgery: Beta human chorionic gonadotropin- positive, hemoglobin-9.8, urinalysis- normal, comprehensive metabolic panel- normal
A laparoscopic surgery performed revealed a hemoperitoneum and hemorrhagic right ovarian cyst with no evidence of ongoing bleeding. The hemoperitoneum was evacuated with an estimated 700 cc of dark blood and clots. No specimen was removed and there was no active bleeding.
Transabdominal and transvaginal ultrasounds were done following the laparoscopy. No intrauterine pregnancy was detected, but it could be too early. There was no ectopic pregnancy detected. There was a 4.9 cm heterogeneous right ovarian lesion with internal hypoechoic material and an additional 3.4 cm simple right ovarian cyst. There was moderate volume pelvic free fluid.
The patient had an uncomplicated observation period and was discharged with strict return precautions. Her post-op hemoglobin was 11.8.
The patient was instructed to follow up with a local provider following discharge.

Conclusions: Over the last few decades, point-of-care ultrasound education and training have expanded the skill of emergency physicians to allow for the rapid assessment of hypotensive patients.
Although many women may have functional ovarian cysts (corpus luteum) during pregnancy, point-of-care ultrasound can assist with the rapid assessment of an ectopic pregnancy or ruptured cyst.
Identification of right upper quadrant free fluid, due to a ruptured cyst or ectopic pregnancy universally results in an exploratory laparoscopy.
Further research measuring the time-to-diagnosis for obstetric patients who require an exploratory laparoscopy following point-of-care ultrasound is a determinant of the impact that this intervention can make on a larger population within a health system.