C H A P T E R

57

Culdocentesis
G. Richard Braen and David Lee Pierce

pelvic pathologic conditions. Conditions in which culdocentesis may be of diagnostic value include a ruptured viscus (particularly an ectopic pregnancy or a corpus luteum cyst), PID, and other intra-abdominal infections (particularly appendicitis with rupture or diverticulitis with perforation), intra-abdominal injuries to the liver or the spleen, and ruptured aortic aneurysms.4

57

Culdocentesis

Ectopic Pregnancy
Culdocentesis is a procedure in which a hollow needle is inserted through the posterior vaginal wall into the peritoneal space to obtain peritoneal fluid for analysis and culture. This procedure is simple, rapid, and safe. The technique is used primarily to diagnose ruptured ectopic pregnancies and ruptured ovarian cysts and, rarely, to obtain cultures to aid in the diagnosis of pelvic inflammatory disease (PID). The availability of high-resolution transvaginal ultrasound and highly sensitive subunit human chorionic gonadotropin (-hCG) quantatative assays have led to a decline in the use of the procedure. Despite this change; however, culdocentesis is still valuable in patients in whom a ruptured ectopic pregnancy is suspected but a sonographic examination cannot be obtained.1 Ectopic pregnancy is often one of the most difficult gynecologic lesions to diagnose.5 The incidence of ectopic pregnancy is on the rise, accounting for 1.6% of all pregnancies. Ectopic pregnancy is the most common obstetric cause of maternal death in the first trimester.5 In a series of 300 consecutive cases of ectopic pregnancy, 50% of patients received medical evaluation at least twice before the correct diagnosis was made.6 In 11% of the patients in this series, the diagnosis was not made until the third medical visit. The clinical picture of ectopic pregnancy may include vascular collapse, pelvic pain, isolated rectal or back pain, amenorrhea, abnormal menses, shoulder pain, syncope, cervical or adnexal tenderness, adnexal mass, anemia, and leukocytosis. It is important to note that blood in the peritoneal cavity does not consistently correlate with peritoneal irritation, blood pressure, or pulse rate.7 In fact, bradycardia in the presence of significant intraperitoneal bleeding from a ruptured ectopic pregnancy is not unusual (Tables 571 and 572). There is often a history of salpingitis, use of an intrauterine contraceptive device, or tubal ligation; however, no combination of these signs, symptoms, or historical data is 1063 diagnostic for an ectopic pregnancy. To confuse the diagnosis further, a normal menstrual history is reported in approximately 50% of patients with ectopic pregnancy. A urine pregnancy test is occasionally negative.8 Although rarely seen, the combination of a uterine decidual cast (Fig. 571) and a positive pregnancy test is virtually pathognomonic of an ectopic pregnancy. A uterine cast is decidua that has been hormonally stimulated by the ectopic pregnancy but is passed vaginally when the tissue can no longer be supported. The cast is an outline of the uterine cavity, but it can be mistaken for products of conception if not inspected carefully. Therefore, all tissue passed vaginally should be carefully inspected before it is sent to the laboratory for analysis for products of conception. Ectopic pregnancy can rarely occur with an intrauterine pregnancy. Patients who have had a therapeutic abortion may actually have had an unrecognized ectopic pregnancy; hence, the need for pathologic evaluation of any tissue obtained by uterine evacuation procedures. The greater sensitivity of the serum and urine -hCG radioreceptor assay, coupled with the proliferation of transvaginal ultrasound and laparoscopy, has greatly increased the chances for early diagnosis of unruptured and ruptured ectopic pregnancy.9 Urinary -hCG tests (enzyme-linked or solidphase immunoassay) provide sensitivity to 20 to 50 mIU/mL, being positive in the first few weeks of pregnancy. However, ectopic pregnancy is often associated with very low production of this hormone. Quantification of the serum test adds additional information being sensitive to 5 mIU/mL. Therefore, a negative urine -hCG test rules out pregnancy in greater than 98% of cases, and pregnancy in any site can be ruled out in virtually all patients with a negative serum -hCG test.10 A single

ANATOMY
Before attempting culdocentesis, the clinician must be familiar with the anatomy of the vagina and rectouterine pouch (pouch of Douglas). In the adult female, the vagina is approximately 9 cm long. From its inferior to its superior aspect, the posterior wall of the vagina is related to the anal canal by way of the perineal body, the rectum, and the peritoneum of the rectouterine pouch.2 The uterus lies nearly at a right angle to the vagina. The rectouterine pouch and the posterior wall of the vagina are adjacent only at the upper quarter (2 cm) of the posterior vaginal wall. The vaginal wall in this area is less than 5 mm thick. The blood supply of the upper vagina comes from the uterine and vaginal arteries, which are branches of the internal iliac artery. The area is drained by a vaginal venous plexus that communicates with the uterine and vesical plexuses. The vagina has its greatest sensation near the introitus and little sensation in the area adjacent to the rectouterine pouch. The rectouterine pouch is formed by reflections of the peritoneum, and it is the most dependent intraperitoneal space in both the upright and the supine positions. Blood, pus, and other free fluids in the peritoneal cavity pool in the pouch because of its dependent location. This pouch separates the upper portion of the rectum from the uterus and the upper part of the vagina. The pouch often contains small intestine and, normally, a small amount of peritoneal fluid.

INDICATIONS
Culdocentesis is indicated in any adult female when fluid aspirated from the rectouterine pouch will help to confirm a clinical diagnosis. If ultrasound examination is not readily available in the emergency department (ED), or if the patient is too hemodynamically unstable to be transported to an offsite location for ultrasound, culdocentesis may be the fastest and most accurate diagnostic technique available to the emergency clinician.3 Analysis of peritoneal fluid is also a reliable method of differentiating inflammatory from hemorrhagic

GENITOURINARY, OBSTETRIC, AND GYNECOLOGIC PROCEDURES

TABLE 571 CorrelationbetweentheResultsofCuldocentesesPerformedon77PatientswithEctopicGestationandVarious ClinicalParameters

ClassicTriad Bleeding Positive Negative Inadequate Total patients 37 8 13 58 Pain 54 8 15 77 Adnexal Mass 10 3 6 19 Peritoneal Signs Pulse 100/min Blood Pressure< 90/40mmHg 9 0 1 10 Mean Hematocrit (%) 35 39 38 65 Hemoperitoneum 100mL Ruptured Tube Total

26 1 5 32

19 1 4 24

52 0 13 37

30 0 7 77

54 8 15

Note: There is a lack of correlation between positive culdocentesis and peritoneal signs and changes in vital signs. Patients are grouped by culdocentesis result (i.e., positive, negative, or inadequate). Note that only 10 patients were hypotensive and only 24 experienced tachycardia. From Cartwright PS, Vaughn B, Tuttle D: Culdocentesis and ectopic pregnancy. J Reprod Med 29:88, 1984. Reproduced by permission.

TABLE 572 CorrelationbetweenTubalStatusandHypotension,Tachycardia,Hematocrit,SignsofPeritonealIrritation,andHemoperitoneumin77PatientswithEctopicGestation

Culdocentesis Ruptured (n = 37) Intact (n = 40) Total patients Culdocentesis Positive 30 24 54 Peritoneal Signs 25 7 32 BloodPressure <90/40mmHg 8 2 10 Pulse 100/min 19 5 24 Hemoperitoneum 100mL 37 28 65 Average Hematocrit(%) 33.6 37.3

IX

Note: Culdocentesis is frequently positive in the absence of rupture. Patients are grouped by the presence (i.e., ruptured) or absence (i.e., intact) of hemoperitoneum. Note that only about half of patients with ruptured status had tachycardia. From Cartwright PS, Vaughn B, Tuttle D: Culdocentesis and ectopic pregnancy. J Reprod Med 29:88, 1984. Reproduced by permission.

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quantitative -hCG is a poor predictor of size of the pregnancy or the risk of ectopic pregnancy, but serial testing is quite helpful. It is expected that the quantitative serum hCG level should double approximately every 2 days in the first trimester. Serum progesterone determinations are not standardly used in the ED, but these may also help to identify a normal or abnormal pregnancy. Although not infallible, a serum progesterone level of less than 10 ng/mL is usually associated with a nonviable intrauterine pregnancy or ectopic pregnancy and a level greater than 25 ng/mL is usually associated with a viable intrauterine pregnancy. To increase the accuracy of diagnosis, it is helpful to combine quantitative -hCG testing with ultrasound examination. An empty uterus by transvaginal or abdominal ultrasound combined with certain quantitative serum -hCG results can be quite helpful to the clinician. The quantitative range in which the ultrasonographer should detect an intrauterine pregnancy varies, but an intrauterine pregnancy should be detected if the serum -hCG level is in the range of 1200 to 1500 mIU/mL when using a transvaginal probe, and greater than 6500 mIU/mL when using a transabdominal probe. Endovaginal ultrasonic scanning consistently identifies a 4week gestational sac if the -hCG level is 2000 mIU/mL or greater. The presence of a fetal pole and cardiac activity are detectable with endovaginal ultrasound scanning at approximately 6 and 7 weeks, respectively.11 It is important to note that the absence of an intrauterine pregnancy by ultrasound, when the -hCG level is below the discriminatory zone associated with positive ultrasound findings, is nondiagnostic and could represent an early viable normal pregnancy, a nonviable intrauterine pregnancy, a completed abortion, or an ectopic pregnancy. When no intrauterine pregnancy is detected by

ultrasound and the serum -hCG exceeds the discriminatory zone, the chance of an ectopic pregnancy ranges from 86% to 100%.12 Culdocentesis, for some patients, may play an important role in the diagnosis of ectopic pregnancy. The test has an accuracy rate of 85% to 95%.3,13,14 Romero and coworkers15 reported that an ectopic pregnancy was found in 99% of patients when a positive pregnancy test and a positive culdocentesis were present. Although culdocentesis is most often positive in the presence of a frankly ruptured ectopic pregnancy, it may be diagnostic even in the nonruptured case when bleeding has been slow or intermittent. Note that many ectopic pregnancies leak varying amounts of blood for days or weeks before rupture. Hemoperitoneum has been found in 45% to 60% of cases of unruptured ectopic pregnancy proven at surgery.7,16 Hence, culdocentesis may be helpful in the stable patient whose ultrasound examination does not demonstrate an intrauterine pregnancy despite a quantitative serum -hCG level in the appropriate range. Although some clinicians opt for outpatient monitoring of serial -hCG levels in this setting, patients for whom the clinician has a high suspicion for ectopic pregnancy (e.g., the patient who has or had significant discomfort) or for whom close follow-up cannot be ensured may be candidates for culdocentesis.3 Although a negative culdocentesis does not rule out an early ectopic pregnancy, patients with a nondiagnostic ultrasound and a negative culdocentesis generally represent patients at lower risk for rupture of an ectopic pregnancy during outpatient serum -hCG monitoring. Patients with a nondiagnostic ultrasound examination and a serum -hCG level below the threshold at which an intrauterine pregnancy should be visible on the ultrasound examination also must be individualized. Those patients with

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TABLE 573 EquipmentforCuldocentesis

Adjustable examination table with stirrups Bivalve vaginal speculum Uterine cervical tenaculum 19-gauge butterfly needle or 18-gauge spinal needle 27- or 25-gauge needle (for local anesthetic infiltration) Ring sponge forceps Syringes (20 mL) Surgical preparation (iodinated, such as povidone-iodine) Sterile water, cotton balls, 4 4 gauze sponges Cocaine (10% solution) or benzocaine (20% solution) Lidocaine (1%) with epinephrine Culture media or test tube without anticoagulant

Culdocentesis

CONTRAINDICATIONS
The contraindications to culdocentesis are relatively few and include an uncooperative patient, a pelvic mass detected on bimanual pelvic examination, a nonmobile retroverted uterus, and coagulopathies. Pelvic masses may include tubo-ovarian abscesses, appendiceal abscesses, ovarian masses, and pelvic kidneys. It has been suggested that the only major risk with the procedure is that of rupturing an unsuspected tuboovarian abscess into the peritoneal cavity. This can be avoided by careful bimanual pelvic examination to exclude patients with large masses in the cul-de-sac.19 Although there are no data to guide the age at which culdocentesis may be safely performed, the procedure is generally limited to patients who are beyond puberty. This limitation is suggested on the basis of anatomy and with the consideration that the procedure is 1065 difficult to perform through a small prepubertal vagina.

Figure 571 This decidual cast, a perfect outline of the uterine cavity, was initially thought to be a product of conception when found in the vaginal vault of a pregnant woman treated for abdominal pain and vaginal bleeding. The initial diagnosis was a spontaneous abortion, but this cast is virtually diagnostic of an ectopic pregnancy. The woman later developed hypotension and was found to have a ruptured tubal pregnancy.

EQUIPMENT
The equipment required for culdocentesis is listed in Table 573. Either an 18-gauge spinal needle or a 19-gauge butterfly needle held by ring forceps is acceptable. It may be helpful to anesthetize the posterior vaginal wall at the site of the puncture with 1% to 2% lidocaine with epinephrine administered through a 27- or 25-gauge needle. Some physicians use a topical anesthetic (eutectic mixture of local anesthetics [EMLA], benzocaine) or a cocaine-soaked cotton ball to anesthetize the mucosa before infiltration with a local anesthetic. Although local anesthesia is often unnecessary (because puncture of the posterior vaginal wall at the upper fourth of the vagina is generally no more painful than a venipuncture), there is some advantage to use of a local anesthetic if multiple attempts at culdocentesis are required, as is sometimes the case. In addition, the epinephrine may produce vasoconstriction and may reduce bleeding associated with the needle puncture. Culdocentesis is often stressful to the patient, and all attempts should be made to render the procedure as painless as possible. Consideration of parenteral analgesia and sedation should also be made when the patient is uncomfortable or anxious.

significant pain, an unexplained low hematocrit reading, or postural vital sign changes (or near syncope) might be candidates for culdocentesis.

Blunt Abdominal Trauma

Historically, the diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been used to identify hemoperitoneum in blunt trauma patients. The use of culdocentesis has also been advocated to aid in this diagnosis.4,17 In the ED, two factors have largely obviated the need to perform invasive procedures to diagnose hemoperitoneum: (1) the increasing availability of high-resolution CT and (2) emergency clinicians trained to perform the bedside ultrasound FAST. (focused assessment with sonography for trauma). However, because small amounts of blood tend to collect in the rectouterine pouch, the aspiration of clear peritoneal fluid is of great potential value in excluding a diagnosis of hemoperitoneum. This is especially helpful in situations in which ultrasound is unavailable or the patient is too unstable to leave the ED for a CT scan. In fact, culdocentesis may be more advantageous than DPL in some instances because there is less risk of urinary bladder perforation or bowel injury. In addition, previous abdominal surgery is not a relative contraindication to culdocentesis, as it is with DPL.18

TECHNIQUE Preparation
Culdocentesis is an invasive procedure that in some hospitals requires a written, witnessed, and signed consent form from the patient, parent, or guardian when the patients condition

GENITOURINARY, OBSTETRIC, AND GYNECOLOGIC PROCEDURES

permits. If verbal consent is obtained, this action should be witnessed and a notation made in the medical record documenting that the procedure was described, complications were discussed, and any alternatives (e.g., CT, sonography, immediate laparoscopy) were offered when appropriate. Once written or verbal consent is obtained, place the patient in a lithotomy position with the head of the table slightly elevated (reverse Trendelenburg position) so that intraperitoneal fluid gravitates into the rectouterine pouch. Place the patients feet in stirrups. Premedicate with intravenous opioids or sedatives if appropriate. The administration of nitrous oxide analgesia also is an accepted practice. When nitrous oxide is used during the procedure, make sure that there is a chaperone in the room (and documented) because some patients develop sexual delusions under this agent. Although pain associated with culdocentesis needle passage is generally minor, the judicious use of analgesia and sedation makes the procedure easier for both clinician and patient. If radiographs are indicated, take them before culdocentesis, to avoid confusion of a procedure-induced pneumoperitoneum.

Urethra Cervix Tenaculum to elevate cervix B

Perform a bimanual pelvic examination before culdocentesis to rule out a fixed pelvic mass and to assess the position of the uterus. It is possible to palpate an adnexal mass if the mass exceeds 3 cm in diameter. Insert the bivalve vaginal speculum and open it widely by adjusting both the height and the angle thumbscrews. Grasp the posterior lip of the cervix with the toothed uterine cervical tenaculum and elevate the cervix (Fig. 1066 572). Warn the patient in advance that she may feel a sharp pain when the cervix is grasped with the tenaculum. Inform the patient also that bleeding from the tenaculum puncture site or culdocentesis site, or both, may produce postprocedure spotting. Use the tenaculum to elevate a retroverted uterus from the pouch, exposing the puncture site, and stabilizing the posterior wall during the needle puncture. Some clinicians prefer to use longitudinal traction on the cervix to produce the same result. The vaginal wall adjacent to the rectouterine pouch will be tightened somewhat between the inferior blade of the bivalve speculum and the elevated posterior lip of the cervix. This tightening of the vaginal wall exposes the puncture site and keeps it from moving away from the needle when the wall is punctured. After the tenaculum is applied and the posterior lip of the cervix is elevated or traction is applied, swab the vaginal wall in the area of the rectouterine pouch with surgical preparation followed by a small amount of sterile water. Administer local anesthesia (1% lidocaine with epinephrine) at this point. Anesthesia may be injected with a separate 27- or 25-gauge needle or by the spinal needle to be used for the culdocentesis. Use a cotton ball soaked in cocaine or benzocaine solution for topical anesthesia of the posterior vaginal wall before infiltration with a local anesthetic. Attach the needle to a 20 mL syringe. A smaller syringe might not be long enough to allow adequate control of the needle, and the clinicians hand may block the view of the puncture site if a smaller syringe is used.

IX

Exposure

B
Figure 572 A, Preparation for culdocentesis. Note that one opens the speculum widely by using both the height (A) and the angle (B) adjustments. The cervix is grasped on the posterior lip with a toothed tenaculum. X marks the site for puncture of the vaginal wall. B, The use of a butterfly needle for culdocentesis. The needle is inserted 1 cm posterior to the point at which the vaginal wall joins the cervix. (A, From Vander Salm TJ, Cutler BS, Wheeler HB: Atlas of Bedside Procedures. Boston, Little, Brown, 1979; B, from Webb MJ: Culdocentesis. JACEP 7:452, 1978.)

Aspiration
Following local anesthesia, advance the syringe and the spinal needle parallel to the lower blade of the speculum. Fill the

syringe with 2 to 3 mL of saline (nonbacteriostatic) before puncture. Following needle puncture, the free flow of the fluid from the syringe expels tissue that may have clogged the needle and confirms that the needle tip is in the proper position and is not lodged in the uterine wall or the intestinal wall. Use saline rather than air, because if air is used, it is difficult to interpret the presence of free peritoneal air on subsequent radiographs. To avoid the need to change the syringe during the procedure, 1% lidocaine may be used for both anesthesia and confirmation of proper needle placement; however, the bacteriostatic property of this agent precludes its use if the procedure is performed to obtain fluid for culture. Penetrate the vaginal wall in the midline 1 to 1.5 cm posteriorly (inferiorly) to the point at which the vaginal wall joins the cervix (Fig. 573).20 Pass the needle a total of 2 to 2.5 cm.20,21 Apply gentle suction with the syringe while slowly withdrawing the needle. Avoid aspirating any blood that has accumulated in the vagina from previous needle punctures or from cervical bleeding because this may give the false impression of a positive tap. Minimize bleeding from the puncture site in the vaginal wall by adding epinephrine to the local anesthetic. Blood or fluid may be obtained immediately but may also be obtained as the needle is withdrawn from the peritoneal

Bladder Pubis Cervix

57

Culdocentesis

Blood Figure 574 Culdocentesis may be performed with a 19-gauge butterfly needle held with ring forceps, or with a spinal needle on a 10-mL syringe. Fill the syringe with saline and confirm intraperitoneal penetration with the free flow of fluid into the cavity, avoiding creation of a pneumoperitoneum. The ringed forceps grasp the wings of the butterfly needle to direct its placement under direct vision. An assistant aspirates for fluid through the proximal end of the tubing. With the spinal needle, the operator applies suction and continues suction during slow withdrawal. (From Webb MJ: Culdocentesis. JACEP 7:451, 1978.)

Rectum

B
Figure 573 The needle is advanced parallel to the lower blade of the speculum. Aspiration is continued throughout the gradual withdrawal of the needle. A, The use of a spinal needle. B, The use of a butterfly needle and ringed forceps. (A, from Vander Salm TJ, Cutler BS, Wheeler HB: Atlas of Bedside Procedures. Boston, Little, Brown, 1979; B, from Webb MJ: Culdocentesis. JACEP 7:452, 1978.)

cavity. Therefore, it is important to aspirate throughout the gradual withdrawal procedure. If no fluid is aspirated, reintroduce the needle and direct it only slightly to the left or right of the midline. Directing the needle too far laterally may result in puncture of mesenteric or pelvic vessels. If no fluid is obtained on the first attempt, repeat the procedure. Some physicians prefer the use of a 19-gauge butterfly needle held with a ring forceps (Fig. 574).20 This technique offers a built-in guide to needle depth and allows for good control of the needle during puncture. An assistant must aspirate the tubing while the physician controls positioning and withdrawal of the needle. Fluid that is aspirated may be old nonclotting blood, bright red blood, pus, exudate, or a straw-colored serous liquid. Any fluid that is not blood should be submitted for Gram staining, aerobic and anaerobic culture, and cell counts. Blood should be observed for clotting. Blood should also be sent for a hematocrit determination.

INTERPRETATION OF RESULTS
An interpretation of the results of culdocentesis depends primarily on whether any fluid was obtained. In the absence of a pathologic condition, one will often aspirate 2 to 3 mL of clear yellowish peritoneal fluid. When there is no return of fluid of any type (a so-called dry tap), the procedure has no diagnostic value. Because a dry tap is nondiagnostic, it should not be equated with normal peritoneal fluid. In addition,

when less than 2 mL of clotting blood is obtained, this is also considered to be a nondiagnostic tap because the source of this small amount of blood may be the puncture site on the vaginal wall. Such blood will usually clot. More than 2 mL of nonclotting blood is certainly suggestive of hemoperitoneum. However, some researchers interpret as little as 0.3 mL of nonclotting blood as a positive tap.7 There is no particular significance to larger amounts of blood, because absolute volume 1067 may be related to the needle position or the rate of bleeding. Brenner and colleagues6 reported no blood from culdocentesis in 5% of patients with proven ectopic pregnancies even when rupture had occurred. In the series of 61 patients with surgically proven ectopic pregnancy reported by Cartwright and associates,7 culdocentesis performed within 4 hours of surgery was positive in 70%, negative in 10%, and inadequate in 20%. Positive in their series was defined as obtaining at least 0.3 mL of nonclotting blood with a hematocrit of greater than 3%. Negative was defined as obtaining 0.3 mL of fluid with a hematocrit of less than 3%. An inadequate tap was one in which no fluid was obtained. In the 252 surgically proven ectopic pregnancy patients having culdocentesis reported by Vermesh and coworkers,16 83% had a positive tap. They defined a positive tap as nonclotting blood with a hematocrit of greater than 15%. Because culdocentesis is usually used to diagnose an ectopic pregnancy, a negative tap is one that yields pus or clear, straw-colored peritoneal or cystic fluid. A large amount of clear fluid (>10 mL) indicates a probable ruptured ovarian cyst, aspiration of an intact corpus luteal cyst, ascites, or possibly, carcinoma. The significance of these fluids and the interpretation of results are outlined in Tables 574 and 575. Elliot and colleagues22 cautioned that obtaining greater than 10 mL of clear fluid should not automatically rule out an ectopic pregnancy because the latter may coexist with other pathologic conditions. A positive tap is one in which nonclotting blood is obtained, although the presence of nonclotted blood does not confirm a tubal pregnancy. Intraperitoneal blood from any source (ectopic pregnancy, ovarian cyst, ruptured spleen) may remain unclotted after aspiration for days in the syringe as

GENITOURINARY, OBSTETRIC, AND GYNECOLOGIC PROCEDURES

TABLE 574 InterpretationofCuldocentesisFluid

AspiratedFluid Clear, serous, strawcolored (usually only a few milliliters) Large amount of clear fluid ConditionandSuggestedDifferential Diagnosis Normal peritoneal fluid

TABLE 575 InterpretationofCuldocentesis

Positive >0.5 mL nonclotting, bloody fluid (hematocrit > 12%) Indicates hemoperitoneum When -hCG also positive, ectopic pregnancy found in greater than 95% Nonspecificcan occur in intrauterine pregnancies and nonpregnant women (e.g., ruptured cyst, retrograde bleeding) Does not necessarily indicate tubal rupture 50%62% of ectopic pregnancies with peritoneal blood may be unruptured Negative Serous fluid Excludes hemoperitoneum and tubal rupture False negative in 10%15% of ectopic pregnancies (generally unruptured) Nondiagnostic Dry tap or clotting blood Excludes neither ectopic pregnancy nor hemoperitoneum 15% of procedures are nondiagnostic 16% of ectopic pregnancies have nondiagnostic study results
-hCG, subunit human chorionic gonadotropin. From Brennan DF: Ectopic pregnancy: II. Diagnostic procedures and imaging. Acad Emerg Med 2:1090, 1995.

Exudate with polymorphonuclear leukocytes Purulent fluid

Bright red blood*

Old, brown, nonclotting blood

Ruptured or large ovarian cyst (fluid may be serosanguineous); pregnancy may be coexistent Ascites Carcinoma Pelvic inflammatory disease Gonococcal salpingitis Chronic salpingitis Bacterial infection Tubo-ovarian abscess with rupture Appendicitis with rupture Diverticulitis with perforation Ruptured viscus or vascular injury Recently bleeding ectopic pregnancy* (ruptured or unruptured) Bleeding corpus luteum Intra-abdominal injury Liver Spleen Other organs Ruptured aortic aneurysm Ruptured viscus Ectopic pregnancy with intraperitoneal bleeding over a few days or weeks Old (days) intra-abdominal injury (e.g., delayed splenic rupture)

IX

COMPLICATIONS
Culdocentesis is one of the safest procedures performed in the emergency setting, and there are probably fewer complications with this technique than with peripheral venous cannulation. Complications have been reported, the most serious being rupture of an unsuspected tubo-ovarian abscess.20 Other complications include perforation of the bowel, perforation of a pelvic kidney, and bleeding from the puncture site in patients with clotting disorders. Because the most common complications result from the puncture of a pelvic mass, careful bimanual examination of the patient should help prevent this problem. Puncture of the bowel and the uterine wall occurs relatively frequently, but this does not generally result in serious morbidity. Obviously, penetration of the gravid uterus has greater potential for harm. Occasionally, one will aspirate air or fecal matter, confirming inadvertent puncture of the rectum. Although this may be disconcerting, it is seldom of serious clinical concern and requires no immediate change in therapy.
REFERENCES
can be found on

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*Note: The hematocrit of blood from a ruptured ectopic pregnancy is usually 15% or greater (97.5% of cases), but some authors use greater than 3% as positive.

a result of the defibrination activity of the peritoneum. The return of a serosanguineous fluid also suggests a ruptured ovarian cyst. The hematocrit of blood from active intraperitoneal bleeding is greater than 10%. In one series, the hematocrit of blood from a ruptured ectopic pregnancy was 15% or greater in 97% of cases.6 It should be emphasized that a positive culdocentesis in the presence of a positive pregnancy test does not always prove an ectopic pregnancy.16 A ruptured corpus luteum cyst in the presence of an intrauterine pregnancy test is probably the most common cause of a false-positive scenario. When possible, ultrasound may help corroborate the culdocentesis findings.

e x p e rt c o n s u lt