Obgyn · Year 3 · from Obgyn

Case 1: Ruptured Ectopic Pregnancy

Patient Demographics

  • Age: 28 years
  • Sex: Female
  • Occupation: Graphic designer

Chief Complaint

"I have sudden severe abdominal pain and I feel dizzy."

History of Present Illness

The patient presents to the emergency department with sudden onset of severe lower abdominal pain that began 2 hours ago while at work. She describes the pain as sharp and constant, initially localized to the right lower quadrant but now diffuse across her lower abdomen. She felt lightheaded and nearly fainted at work, prompting her coworkers to call an ambulance. She reports right shoulder pain that began about 30 minutes after the abdominal pain started. She has had scant vaginal spotting for the past week. Her last menstrual period was 7 weeks ago, and her periods are usually regular every 28 days. She had unprotected intercourse with her partner, and they have been casually trying to conceive. She has not yet taken a home pregnancy test.

Past Medical History

  • Chlamydia infection treated at age 22
  • Pelvic inflammatory disease at age 24, treated with outpatient antibiotics
  • G1P0010 (one prior first-trimester surgical abortion at age 20)
  • No prior surgeries other than the D&C

Physical Examination Findings

  • Vital Signs: BP 88/52 mmHg, HR 124 bpm, RR 22, Temperature 36.8 degrees Celsius, O2 saturation 98% on room air
  • General: Pale, diaphoretic woman in moderate distress, clutching her abdomen
  • Cardiovascular: Tachycardic, regular rhythm, weak peripheral pulses
  • Abdomen: Diffusely tender with involuntary guarding, rebound tenderness throughout, absent bowel sounds, no distension initially noted
  • Pelvic Examination: Scant dark blood in vaginal vault, cervix closed, exquisite cervical motion tenderness, fullness and tenderness in bilateral adnexa, bulging and tender cul-de-sac

Diagnostic Workup

  • Urine Pregnancy Test: Positive
  • Serum beta-hCG: 8,450 mIU/mL
  • Complete Blood Count: Hemoglobin 8.2 g/dL (low), Hematocrit 24%, WBC 11,200/microL, Platelets 245,000/microL
  • Type and Screen: O positive, antibody screen negative
  • Point-of-Care Ultrasound (POCUS) - Bedside: No intrauterine pregnancy visualized, complex free fluid throughout the abdomen and pelvis, large amount of echogenic fluid (hemoperitoneum) in Morison's pouch and pelvis
  • Formal Transvaginal Ultrasound: Empty uterus with 6 mm endometrial stripe, no intrauterine gestational sac, large amount of echogenic free fluid in the cul-de-sac, right adnexal mass measuring 3.2 cm with possible extrauterine gestational sac (ring sign)

Diagnosis

Ruptured Ectopic Pregnancy with hemoperitoneum and hemorrhagic shock

  • Confirmed by: positive pregnancy test, empty uterus on ultrasound with beta-hCG above discriminatory threshold, right adnexal mass, large hemoperitoneum, hemodynamic instability

Initial Resuscitation and Management

Immediate Interventions (within minutes of arrival):

  1. Two large-bore IV access (16-gauge or larger) - bilateral antecubital
  2. Activate massive transfusion protocol
  3. Send type and crossmatch for 4 units PRBCs
  4. Begin crystalloid resuscitation with 1-2 liters warmed lactated Ringer's
  5. Obtain O-negative uncrossmatched blood if transfusion needed before crossmatch completed
  6. Foley catheter to monitor urine output
  7. Call OR for emergent surgery
  8. Notify anesthesia and gynecology attending

Blood Product Administration:

  • 2 units O-negative PRBCs transfused emergently
  • Type-specific blood available within 20 minutes
  • Goal: maintain hemoglobin >7 g/dL, blood pressure >90 mmHg systolic

Surgical Management

Procedure: Emergent laparoscopic right salpingectomy

Operative Findings:

  • 1,500 mL of blood and clot evacuated from the peritoneal cavity
  • Ruptured right tubal ectopic pregnancy in the ampullary segment with active bleeding from the rupture site
  • Left fallopian tube and both ovaries appear grossly normal
  • No evidence of endometriosis or adhesions

Procedure Performed:

  • Right salpingectomy (removal of the right fallopian tube)
  • Salpingectomy chosen over salpingostomy because:
  • Ruptured ectopic with hemodynamic instability
  • Salpingostomy associated with higher persistent ectopic rate
  • Left tube appears normal, preserving fertility potential
  • Copious irrigation of the pelvis
  • Hemostasis achieved

Intraoperative Management:

  • Total blood loss estimated at 1,800 mL
  • 4 units PRBCs, 2 units FFP, 1 unit platelets transfused
  • Hemoglobin post-transfusion: 9.8 g/dL
  • Hemodynamically stable at end of case

Postoperative Care

Immediate Postoperative:

  1. ICU admission for monitoring overnight
  2. Serial hemoglobin checks every 6 hours
  3. IV fluids until tolerating oral intake
  4. Incentive spirometry and DVT prophylaxis

RhoGAM Administration:

  • Patient is Rh-positive, so RhoGAM not indicated
  • Note: If Rh-negative, would administer 50 mcg RhoGAM for early pregnancy loss or 300 mcg if beyond 12 weeks

Day 1 Postoperative:

  • Hemodynamically stable
  • Hemoglobin stable at 9.4 g/dL
  • Tolerating regular diet
  • Ambulatory
  • Transferred to floor

Discharge Planning (Day 2):

  1. Oral iron supplementation for 3 months
  2. Pelvic rest for 2 weeks
  3. Follow-up beta-hCG in 1 week (should be undetectable)
  4. Contraception counseling until ready for pregnancy
  5. Future fertility counseling

Future Pregnancy Counseling:

  • Risk of recurrent ectopic pregnancy: 10-15% (elevated due to history of PID and prior ectopic)
  • Early ultrasound recommended in any future pregnancy (at 6 weeks) to confirm intrauterine location
  • One remaining fallopian tube - pregnancy still possible
  • If difficulty conceiving, may need IVF

Follow-up:

  • Beta-hCG 1 week post-op: <5 mIU/mL (appropriately undetectable)
  • 2-week postoperative visit: incisions healing well, no complications
  • Histopathology confirmed ectopic pregnancy in right fallopian tube

Clinical Image

Image Description: Transvaginal ultrasound demonstrating findings of ectopic pregnancy. The image shows an empty uterus without an intrauterine gestational sac (left panel). The right adnexa shows a tubal ring sign representing the extrauterine gestational sac with surrounding echogenic free fluid consistent with hemoperitoneum (right panel). These findings in the presence of a positive pregnancy test are diagnostic of ectopic pregnancy.

Attribution: Ectopic pregnancy ultrasound findings as described in Radiopaedia (https://radiopaedia.org/articles/ectopic-pregnancy) and radiology literature.

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