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This is an ultrasound of the pelvis

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in a patient with a positive home

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pregnancy test presenting with left lower

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quadrant abdominal pain and tachycardia.

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We have transabdominal images of the pelvis

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and a long view or sagittal view of the uterus.

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As we evaluate the endometrial cavity, we see

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the hyperechoic endometrial stripe without

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a visible intrauterine gestational sac.

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Additional transverse plane images of the

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uterus again demonstrate normal myometrium

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and a hyperechoic endometrial stripe.

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Endometrium without a gestational sac visible.

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The right ovary is identified on transabdominal

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imaging and is normal in size and appearance.

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In the left adnexa, posterior and lateral

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to the uterus, which is located here,

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there is a heterogeneously hyperechoic

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and hypoechoic mass measuring at least 6.1 centimeters.

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21 00:00:56,680 --> 00:00:58,099 Within the mass, we can see a

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discrete hyperechoic ring-like

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structure with central heterogeneity.

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Evaluation of the upper abdominal

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quadrants demonstrates significant free

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fluid adjacent to the right kidney.

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Transvaginal images of the pelvis at the level

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of the uterus and cervix also demonstrate

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significant free fluid in the cul-de-sac.

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It can be noted that the endometrium is

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thickened without a gestational sac present.

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Transvaginal ultrasound images of the

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heterogeneous left adnexal mass again

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demonstrate heterogeneously hypoechoic tissue.

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With a peripherally hyperechoic

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structure with central hypoechogenicity.

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Lace-like echoes and free fluid are seen

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adjacent to the mass in the left adnexa,

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suggestive of clotted blood products.

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On these color Doppler transvaginal images

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of the left adnexa, we again see the lesion,

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which is a ring-like hyperechoic structure

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with intense peripheral vascularity.

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This is known as the ring of fire sign.

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This is an additional transvaginal

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ultrasound image of the left adnexa, where

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we see a ring-like hypoechoic structure

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with central hypoechoic components.

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Lastly, these are transverse transvaginal

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images of the uterus from inferior to superior.

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We can see that surrounding the uterus

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there's a significant amount of free fluid.

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I want to point out the

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appearance of the fluid here.

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This is not just simple fluid, right?

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Simple fluid in the pelvis looks

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anechoic and would be darker than this.

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Anytime you see free fluid in the pelvis

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that looks like it's a handful of sand that's

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been dumped into a jar of water and shaken up.

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This grainy, slightly hyperechoic

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appearance, these are blood products.

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So this patient has a significant

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amount of pelvic hemoperitoneum.

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To summarize, we have a ring-like,

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hypervascular structure in the left adnexa

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with adjacent clotted blood products and

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significant abdominal pelvic hemoperitoneum.

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This patient was taken to surgery and

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a diagnosis of ruptured left tubal

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ectopic pregnancy was confirmed.