Do You Recognize the Classical Clinical Triad in This Emergency Case?

A 35-year-old female, G0P0, presents to the emergency department with lower abdominal pain and vaginal spotting. Her last menstrual period was nine weeks ago. She was treated for a chlamydial cervical infection in the past, and has never taken oral contraceptives. On abdominal examination, no mass is detected, however, there is moderate tenderness in the right adnexal region. Laboratory studies reveal mildly low hemoglobin and elevated beta-hCG levels. An ultrasound demonstrates the findings seen here. Which of the following features is consistent with this patient’s most likely diagnosis?



A) Cervical dilation
B) Doubled beta-hCG level at 48 hours
C) Grape-shaped discharge
D) Uterine enlargement


Answer: Uterine enlargement

This patient’s presentation is characteristic of an ectopic pregnancy. In this condition, where the fertilized ovum implants outside the uterine cavity, a classic clinical triad of pain, amenorrhea, and vaginal spotting is seen in approximately 50% of patients. The differential diagnosis also includes a threatened or complete miscarriage, and a molar pregnancy. A miscarriage typically presents with cervical dilation as a hallmark feature, while the vaginal passage of grape-shaped tissue is often seen in molar pregnancies. Normally, beta-hCG levels will double every 48-72 hours. In ectopic pregnancy, the beta-hCG levels rise at a lower rate (less than 66% in 48 hours). Even in an ectopic location, implantation promotes placental beta-hCG release causing vascular, glandular, and stromal changes, resulting in uterine enlargement.

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