A 23-year-old woman (gravida 3, para 2) at 7 weeks gestational age presented to the labor and delivery emergency department with painless, minimal vaginal spotting. On physical examination her vital signs were stable, with blood pressure of 120/88 mm Hg and a pulse rate of 85 beats/min. Her serum β-human chorionic gonadotropin (hCG) level was 433 mIU/mL. The patient denied medical or surgical history aside from 2 uncomplicated vaginal deliveries, a normal menstrual cycle, and no use of contraception, alcohol, or illicit drugs. An osteopathic structural examination (OSE) of the thoracic and lumbar spines, rib cage, and sacrum was performed and revealed that T1-T12 and L1-L5 were neutral, rotated left, and sidebent right and the sacrum was rotated left on a left oblique axis. No Chapman reflex points were identified at this time. Transvaginal ultrasonography revealed a normal uterus and adnexal structures, no free fluid in the pelvis, and no intrauterine pregnancy (IUP). The patient was given the diagnosis of pregnancy of an unknown location, counseled on the possibility of an ectopic pregnancy, and instructed to return for a follow-up evaluation within 48 hours for repeated serum β-hCG level testing.
The patient did not keep her follow-up appointment, but she returned to the emergency department 2 weeks later with severe abdominal pain over the past 3 hours. She denied any vaginal bleeding, nausea, or vomiting. Her vital signs at the time of presentation were stable (blood pressure, 117/82 mm Hg, and pulse rate, 88 beats/min). However, physical examination revealed diffuse abdominal tenderness, guarding, and signs of acute abdomen with increasing lethargy. An OSE of the thoracic and lumbar spines, rib cage, and sacrum was performed and revealed that T1-T8 and L1-L5 were neutral, rotated left, and sidebent right; T9-T12 were flexed, rotated right, and sidebent right; and the sacrum was rotated left on a left oblique axis. Chapman reflex points were identified anteriorly in the intercostal space between the 9th and 10th and the 10th and 11th ribs near the costochondral junction, bilaterally and posteriorly between the transverse processes of T9 and T10 and T10 and T11, and halfway between the spinous processes and the tips of the transverse processes.
Transvaginal ultrasonography images revealed an 8-mm endometrial stripe, large amounts of complex fluid with internal echoes around the uterus and both adnexa (most likely representative of a hemoperitoneum) (
Figure 1A), and a 0.5-cm left adnexal cystic structure with focal increased vascularity (
Figure 1B). Her serum β-hCG level was 333 mIU/mL, and a complete blood cell count revealed a hemoglobin level of 10.9 g/dL, hematocrit of 35%, and a white blood cell count of 19.6 × 10
9/L. These findings were highly suggestive of a ruptured ectopic pregnancy, and the patient underwent an emergent laparotomy.
An exploratory laparotomy revealed 1500 mL of hemoperitoneum and a normal uterus with intact ovaries, ligaments, and fallopian tubes. A brownish-red encapsulated soft nodular tissue measuring approximately 2 cm × 2 cm, easily palpated, was clearly seen on the left side of the omentum (
Figure 1C). The gestational sac was identified with surrounding blood clots. A left partial omentectomy was also performed with a wide omental excision technique to avoid leaving trophoblastic tissue behind. An examination of the remaining contents of the pelvis and abdominal cavity revealed no abnormal tissue. Histopathologic analysis revealed focally hemorrhagic fibroadipose tissue, reactive lymph nodes, and products of conception consisting of immature chorionic villi in the supporting tissue (
Figure 1D). The patient had an uneventful recovery, with down-trending serum β-hCG levels over the course of 2 weeks.