Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Ectopic Pregnancy - The Ruptured Tubal Pregnancy

Patient Demographics

  • Age: 28 years
  • Sex: Female
  • Occupation: Elementary school teacher

Chief Complaint

"I have severe pain in my lower belly and I feel like I'm going to pass out."

History of Present Illness

A 28-year-old female presents with sudden onset of severe left lower quadrant abdominal pain that began 2 hours ago. She reports associated lightheadedness, especially when standing. Her last menstrual period was 7 weeks ago, and she typically has regular cycles. She reports recent vaginal spotting (light) for 3 days. She has not had a positive home pregnancy test.

Initial Assessment

ESI Level: 1 - Hemodynamically unstable with suspected ruptured ectopic

First Impression:

  • Appearance: Pale, diaphoretic, in obvious distress
  • Work of breathing: Mildly tachypneic
  • Circulation: Pale, clammy skin

Vital Signs:

  • Heart rate: 124 bpm
  • Blood pressure: 86/52 mmHg (supine)
  • Respiratory rate: 22 breaths/min
  • SpO2: 98% on room air
  • Temperature: 36.8C

Orthostatic Assessment (not performed due to hypotension)

Primary Survey

Airway: Patent Breathing: Tachypneic, clear lungs Circulation: Tachycardic, hypotensive, weak peripheral pulses, cap refill 4 seconds Disability: Alert but anxious, GCS 15 Exposure: No external hemorrhage, abdomen distended

Resuscitation

Immediate Interventions:

  1. Two large-bore IVs (16-gauge)
  2. Aggressive crystalloid resuscitation: 2L LR bolus
  3. Type and crossmatch for 4 units PRBCs
  4. Activate massive transfusion protocol standby
  5. Point-of-care pregnancy test
  6. Bedside ultrasound

Point-of-Care Results:

  • Urine pregnancy test: POSITIVE
  • Hemoglobin: 7.2 g/dL (critical)

Bedside Ultrasound (FAST + Pelvic)

Findings:

  • Free fluid: Significant free fluid in Morison's pouch and pelvis
  • Uterus: Empty - no intrauterine pregnancy (IUP)
  • Adnexa: Left adnexal mass with surrounding complex free fluid
  • Interpretation: Ruptured ectopic pregnancy with hemoperitoneum

Secondary Survey

SAMPLE History:

  • Symptoms: Sudden severe LLQ pain, lightheadedness, vaginal spotting
  • Allergies: None
  • Medications: None
  • PMH: Chlamydia infection 3 years ago (treated), 1 prior pregnancy (G1P1)
  • LMP: 7 weeks ago
  • Last Meal: Lunch 4 hours ago
  • Events: Sudden onset pain

Risk Factors for Ectopic Pregnancy:

  • Prior pelvic infection (chlamydia) - PRESENT
  • Tubal surgery - No
  • Prior ectopic - No
  • IUD use - No
  • Infertility treatment - No
  • Smoking - No

Physical Examination:

Abdominal:

  • Distended
  • Diffusely tender, worse LLQ
  • Guarding and rebound present
  • Involuntary rigidity

Pelvic Exam (performed by OB/GYN):

  • Scant dark blood in vaginal vault
  • Cervical os closed
  • Significant cervical motion tenderness
  • Left adnexal tenderness with mass
  • Cul-de-sac fullness

Diagnostic Testing

Labs:

  • CBC: Hgb 7.2, Hct 22%, Plt 234
  • Type and screen: O positive
  • Quantitative beta-hCG: 4,200 mIU/mL
  • Coagulation: PT/INR normal, PTT normal

Transvaginal Ultrasound (if stable - not performed here due to hemodynamic instability):

  • Would show empty uterus, adnexal mass, free fluid

Diagnosis

Ruptured left tubal ectopic pregnancy with hemorrhagic shock

Management

Resuscitation Continued:

  • Total 3L crystalloid
  • 2 units PRBCs transfused
  • Vitals improved: HR 108, BP 98/64

Emergency OB/GYN Consultation:

  • Emergent operative intervention indicated
  • Patient consented for surgery

Surgical Management:

  • Emergent laparoscopy (converted to laparotomy due to hemorrhage)
  • 1.5L hemoperitoneum evacuated
  • Ruptured left tubal ectopic identified
  • Left salpingectomy performed
  • Estimated blood loss: 2L total

Disposition

  • Post-operative recovery
  • Total transfusion: 4 units PRBCs
  • Stable post-operatively
  • Discharged POD 2
  • OB/GYN follow-up arranged
  • Counseling regarding future fertility

Teaching Points

  1. Think ectopic: Any reproductive-age female with abdominal pain - pregnancy test first
  2. Ruptured ectopic is surgical emergency: Hemodynamically unstable patients go to OR, not radiology
  3. Discriminatory zone: Beta-hCG >2000-3000 should show IUP on TVUS; absence suggests ectopic
  4. Bedside ultrasound: Identify free fluid and empty uterus to support diagnosis
  5. Hemorrhage management: Aggressive resuscitation, blood products, and surgical control
  6. Risk factors: Prior STI, ectopic, tubal surgery increase risk significantly
  7. Future fertility: Counsel regarding increased risk of recurrent ectopic

Clinical Image

Image Description: Transvaginal ultrasound demonstrating an empty uterus with an adnexal mass (tubal ring sign) and surrounding free fluid, consistent with ectopic pregnancy.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Yuranga Weerakkody. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/ectopic-pregnancy-tubal

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