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Emergency Medicine

Training Level

Resident PGY 2


Henry Ford Macomb


Introduction: Abnormal non-pregnant uterine bleeding is a common gynecological complaint encountered in the emergency department. Emergency physicians must be able to differentiate life threatening bleeding from non-life threatening bleeding. The differential diagnosis can include endometriosis, sexually transmitted disease, fibroids. The differential becomes even more narrow when your exam shows an expelled uterus shaped mass. Uterine or decidual casts are a rare clinical finding, and diagnosis. The decidua forms because of the effect of progesterone on the lining of the uterus. The uterine cast forms when the entire lining is sloughed off at once. These have been reported as a side effect of human menopausal gonadotrophin, human chorionic gonadotrophin, and progestogens.

Case Presentation: 56 y.o. obese female with history of diabetes mellitus, endometrial hyperplasia, factor V leiden, lower extremity lymphedema who presents to ED with vaginal bleeding with associated lower abdominal pain that started tonight. She described the abdominal pain as an intermittent achy sensation. Pt is bedridden. Tonight, she was in bed, and states that her daughter in law was bathing her and noted a large amount of bright red vaginal bleeding. Pt reports hx of endometrial hyperplasia dx in 2017. Pt has been on Megace (megestrol acetate) for years. She states that she is post menopausal and has not had a menstrual period in years. No previous gynecological surgeries.

Physical Exam: Vital Signs showed blood pressure 148/78, heart rate 77, Temperature 36.7, respiratory rate 18, Weight 213kg, BMI 85. Her abdominal exam was non tender throughout. Pt noted to be obese. A pelvic exam was performed. Pt noted to have a foley catheter in place with clear-yellow urine. There was bleeding noted in the vaginal canal. A large 12 cm bloody tissue was found partially in the vaginal canal that was removed.

Results: Labs were significant for HGB 15.7,WBC 12.2. PT/PTT/INR within normal limits. Urinalysis showed no signs of infection, urine pregnancy negative.

Pathology report: Uterine cast consistent with marked progestin effect. No evidence of malignancy.

Interventions: Patient was given Morphine for pain control. OB/GYN was consulted and agreed with the diagnosis of uterine cast. Vaginal bleeding had subsided. Pt was continued on Megace for her hyperplasia.

Discussion: The identification of a uterine cast may be difficult as it is not well known and not commonly seen in the emergency department. The diagnosis of uterine cast in the patient was suspected based on her past medical history. The formation of the uterine cast in this patient maybe due to a combination of her past medical history of endometrial hyperplasia and current treatment with megestrol acetate. The diagnosis was confirmed by pathology. In premenopausal women, uterine casts have a known association with ectopic pregnancies. This is important in the setting of the emergency department as undiagnosed ectopics can be life threatening. Women who present with vaginal bleeding, elevated beta- HCG, and passage of a uterine cast, could be mistaken for gestational sac resulting in missed diagnosis of ectopic pregnancy. Uterine or decidual casts are a rare clinical finding, and diagnosis that should be considered with abnormal uterine bleeding. They can be non-life threating in cases where they result from side effect of exogenous hormones but can be potentially life-threatening when presenting in the setting of an ectopic pregnancy.

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