Obstetrics and gynaecology · Hard
This case is fictional and exists for study. It describes no real patient.
28 years · female
A 28-year-old female presents to the emergency department with a 6-hour history of sudden-onset, severe left lower abdominal pain that radiates to her left shoulder tip. She reports 6 weeks of amenorrhoea and light vaginal spotting for two days. She appears pale, diaphoretic, and distressed. Abdominal examination demonstrates left iliac fossa tenderness with local involuntary guarding and rebound tenderness. Bimanual pelvic examination reveals exquisite cervical motion tenderness and left adnexal tenderness. Transvaginal ultrasonography reveals an empty uterine cavity, a 3.2 cm complex left adnexal mass, and moderate free fluid in the Pouch of Douglas.
Vital signs
- HR
- 118 bpm
- BP
- 92/58 mmHg
- RR
- 22/min
- Temp
- 36.8 °C
- SpO₂
- 97%
Examination findings
- Pale and diaphoretic appearance
- Left iliac fossa tenderness with guarding and rebound tenderness
- Cervical motion tenderness (excitation mark)
- Left adnexal tenderness
Investigations
| Haemoglobin | 9.1 g/dL | reference: 12.0-15.5 |
| Serum beta-hCG | 2450 IU/L | reference: <5 |
Question 1 of 3
Which of the following is the most appropriate next step in management for this patient?
This patient has a ruptured ectopic pregnancy: six weeks of amenorrhoea with a positive beta-hCG, left iliac fossa peritonism, and shoulder tip pain — referred pain from diaphragmatic irritation by intraperitoneal blood — in a patient who is pale, diaphoretic and haemodynamically unstable. That combination is enough to act on; no imaging is needed to justify surgery, and waiting for it costs blood. The priority is fluid resuscitation and emergency surgical intervention (laparoscopy or laparotomy depending on stability and surgical expertise). Methotrexate is strictly contraindicated in haemodynamic instability. Serial beta-hCG and repeat imaging belong to the stable patient, not this one.
Teaching point: Haemodynamic instability or acute abdominal signs in ectopic pregnancy are absolute indications for immediate resuscitation and surgical management.
Question 2 of 3
Which physiological mechanism best explains this patient's left shoulder tip pain?
Shoulder tip pain (Kehr's sign) occurs when free blood in the peritoneal cavity collects beneath the diaphragm, irritating the sensory fibers of the phrenic nerve (C3-C5). This pain is referred to the dermatomes of C3-C5 over the shoulder tip. Uterine distension, ovarian stretch, and ureteral obstruction cause distinct local or loin/groin pain patterns and do not account for diaphragmatic referred shoulder pain.
Teaching point: Shoulder tip pain in suspected ectopic pregnancy indicates significant intra-abdominal bleeding (haemoperitoneum) causing phrenic nerve irritation.
Question 3 of 3
Prior to transferring the patient to the operating theatre, which blood test is most crucial to draw immediately?
Blood grouping, Rh typing, and crossmatching are essential immediately prior to surgery in an unstable patient with intra-abdominal haemorrhage. This ensures blood products can be administered rapidly if transfusion is required and identifies Rh-negative status, which necessitates administration of anti-D immunoglobulin to prevent Rh alloimmunization. Serum progesterone and repeat beta-hCG offer no utility in the emergency setting. A coagulation screen may be done, but obtaining crossmatched blood and knowing Rh status is the single most critical priority.
Teaching point: Always perform urgent blood grouping, Rh typing, and crossmatch in patients with suspected intra-abdominal bleeding from ectopic pregnancy.
Key learning points
- Haemodynamic instability, acute abdomen, or sign of haemoperitoneum in ectopic pregnancy demands immediate resuscitation and surgical intervention.
- Methotrexate is contraindicated in the presence of rupture, severe pain, intra-abdominal bleeding, or haemodynamic instability.
- Shoulder tip pain (Kehr's sign) results from diaphragmatic irritation by haemoperitoneum via C3-C5 phrenic nerve pathways.
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