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FF in Morrison's and Specificity for Ruptured Ectopic
Posted: Tuesday, July 9, 2013
Joined: 3/12/2011
Posts: 1

Posted on behalf of Drew from the listserv:

I am a new ultrasound director and am working on a lecture for my group tomorrow and am briefly discussing the case of a young woman with a ruptured ectopic pregnancy.  My question is in regards to the specificity and PPV for a ruptured ectopic pregnancy in a woman of child-bearing age with atraumatic abdominal pain, and free fluid in Morrison's pouch PRIOR to pregnancy testing.  While I am aware of the data in regards to women who are known to be pregnant, in this particular case the ultrasound was obtained before the urine HCG or a serum HCG was obtained, and the patient did not know she was pregnant.  I am curious if this has ever been looked into.  I have done my own lit search and am coming up empty-handed.  Thus my appeal to those of you across the country who have paved the roads before me.

Andrew Shedd, MD
Emergency Physician
Emergency Ultrasound Director
Baylor University Medical Center
Dallas, TX

Posted: Thursday, July 18, 2013
Joined: 8/31/2011
Posts: 231

Dear Drew,

Yes, I had such a case at Harris in FW, TX in which a 26 yo s/p BTL had free fluid (blood) in Morison's pouch and looked like a ruptured ectopic case.  HCG then came back negative - a which point OB signed off.  Source of blood was a renal cell carcinoma with free intraperitoneal hemorrhage.  Went to OR for Nephrectomy.

Dave Spear, MD
Harris Methodist Forth Woth
Posted: Thursday, July 18, 2013
Joined: 8/31/2011
Posts: 231

Hemorrhagic corpus luteum cyst with shock. Looked very much like ruptured ectopic.

Sam G. Morale, M.D.
Posted: Thursday, July 18, 2013
Joined: 8/31/2011
Posts: 231

See abstract from 2007 article below.
Of 242 patients with early pregancy, 28 ectopics, free fluid in 10 - 9 ectopics, one was a ruptured ovarian cyst.
Would definitely get a pregnancy test - if so very likely (but not 100%) to be ruptured ectopic needing operative intervention.
If negative, very likely to be ruptured ovarian cyst (which still may require operative intervention).
Absence of FF does not r/o ectopic, but presence makes operative intervention much more likely to be required.

Chris Moore

Free Fluid in Morison’s Pouch on Bedside
Ultrasound Predicts Need for Operative
Intervention in Suspected Ectopic Pregnancy
Chris Moore, MD, William M. Todd, MD, Elizabeth O’Brien, MD, Henry Lin, MD
Background: Ectopic pregnancies are frequently present in women who present to the emergency department
with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention.
Objectives: To prospectively determine if emergency physician (EP)-performed transabdominal pelvic
ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the
need for operative intervention.
Methods: Patients who were suspected to have an ectopic pregnancy were prospectively enrolled over
a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the
hepatorenal space (Morison’s pouch) for free fluid. The EP US was classified as intrauterine pregnancy
(IUP) or no definitive IUP, with Morison’s pouch classified as positive or negative. The majority of patients
had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients
were followed up for radiology results, need for operative intervention, and ultimate outcome of the
Results: There were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27
seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative
intervention. Free fluid in Morison’s pouch was identified in ten patients, nine of whom underwent operative
intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for
patients with suspected ectopic pregnancy who required operative intervention.
Conclusions: Free intraperitoneal fluid found in Morison’s pouch in patients with suspected ectopic pregnancy
may be rapidly identified at the bedside by EP-performed US and predicts the need for operative

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