Obstetrics and gynaecology · Hard
This case is fictional and exists for study. It describes no real patient.
29 years · female
A 29-year-old woman presents to the emergency department at 7 weeks gestation with sudden-onset, severe right lower quadrant pain and light, dark vaginal bleeding for 6 hours. She reports feeling lightheaded upon standing. Her obstetric history includes one previous uncomplicated full-term delivery and a history of pelvic inflammatory disease two years ago. On examination, she appears pale and diaphoretic. Abdominal examination demonstrates marked right iliac fossa tenderness with local guarding and rebound tenderness. Bimanual pelvic examination reveals significant cervical motion tenderness and right adnexal tenderness. Speculum examination shows a closed cervical os with a small amount of dark blood in the vaginal vault.
Vital signs
- HR
- 118 bpm
- BP
- 88/56 mmHg
- RR
- 22/min
- Temp
- 36.6 °C
- SpO₂
- 98%
Examination findings
- Pale and diaphoretic appearance
- Right iliac fossa tenderness with guarding and rebound tenderness
- Cervical motion tenderness and right adnexal fullness
- Closed cervical os with minimal dark vaginal blood
Investigations
| Haemoglobin | 9.2 g/dL | reference: 12.0-15.5 |
| Serum beta-hCG | 2800 IU/L | reference: N/A |
| Blood Group & Rh | O RhD-negative | reference: N/A |
Question 1 of 3
What is the most likely diagnosis?
The clinical presentation of severe lower abdominal pain, dark vaginal bleeding, cervical motion tenderness, peritoneal signs (guarding, rebound tenderness), haemodynamic collapse (hypotension, tachycardia), and elevated serum beta-hCG strongly points to a ruptured ectopic pregnancy. An incomplete miscarriage typically features an open cervical os with tissue passage. A threatened miscarriage presents with bleeding and a closed os, but without haemodynamic instability or peritoneal signs. A ruptured corpus luteum cyst can cause haemoperitoneum, but a positive pregnancy test with high beta-hCG and risk factors like previous PID make ectopic pregnancy the primary diagnosis.
Teaching point: A positive pregnancy test combined with haemodynamic instability, unilateral lower abdominal pain, and peritoneal signs must be managed as a ruptured ectopic pregnancy until proven otherwise.
Question 2 of 3
What is the most appropriate next step in the immediate management of this patient?
In a haemodynamically unstable patient with suspected ruptured ectopic pregnancy, immediate vascular access, fluid resuscitation, crossmatching blood, and urgent surgical intervention (laparoscopy or laparotomy) are required. Methotrexate is strictly contraindicated in haemodynamically unstable patients or cases of ruptured ectopic pregnancy. Serial beta-hCG monitoring is reserved for stable pregnancy of unknown location (PUL). Delaying treatment to send an unstable patient to radiology for an ultrasound is unsafe; bedside ultrasound may be used during resuscitation, but definitive surgical control of bleeding cannot be delayed.
Teaching point: Haemodynamically unstable patients with a suspected ruptured ectopic pregnancy require immediate resuscitation and urgent emergency surgery.
Question 3 of 3
In addition to surgical management and blood transfusion, which intervention is essential for this patient?
The patient is RhD-negative. Non-sensitized RhD-negative women who undergo surgical management for an ectopic pregnancy must receive anti-D immunoglobulin (at least 250 IU or 1500 IU depending on gestation/guidelines, typically within 72 hours) to prevent Rh isoimmunization. Progesterone supplementation has no role in ectopic pregnancy management. Routine uterine curettage is unnecessary and invasive. Prophylactic oral antibiotics for 14 days are not indicated without confirmed pelvic infection.
Teaching point: All non-sensitized RhD-negative women undergoing surgical intervention for an ectopic pregnancy must receive anti-D immunoglobulin within 72 hours.
Key learning points
- Ruptured ectopic pregnancy is a life-threatening surgical emergency presenting with bleeding, pain, peritoneal irritation, and haemodynamic instability.
- Haemodynamically unstable patients with suspected ectopic pregnancy require immediate fluid resuscitation and urgent surgical control, bypassing non-essential delays.
- Anti-D immunoglobulin must be administered to non-sensitized RhD-negative women within 72 hours of surgical management for ectopic pregnancy.
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