What Cause of Abdominal Pain, Vaginal Bleeding in a Young Woman?

August 18, 2014

The pain and bleeding have persisted for 2 days. She last menstruated 5 weeks ago but doubts she is pregnant. Take a close look at the ultrasound image. Your Dx?

A 26-year-old woman with a history of asthma, appendectomy, and ovarian cyst presents to the ED with lower abdominal pain accompanied by vaginal bleeding of 2 days' duration. She denies any recent fever, vomiting, vaginal discharge besides blood, or other associated symptoms.  She states that she is sexually active with her husband and they use condoms for contraception. She thinks her last menstrual period was about 5 weeks ago but she is often irregular and so has not performed a home pregnancy test.

Her vital signs are all normal.  Her head and neck examination is unremarkable and her lungs are clear without wheezing. The rest of her physical examination is essentially normal except for mild suprapubic tenderness. The pelvic examination was deferred as it was considered to be low yield.

A urine analysis and complete blood count (CBC) are performed with results that are normal but, perhaps not surprisingly, her pregnancy test comes back positive. A pelvic sonogram is completed by the ultrasound technologist. One of the transvaginal images is shown in the Figure.

What does the sonogram show?

What is your diagnosis? 

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