Ruptured ectopic pregnancy with shock
The case
A 32-year-old woman at 7 weeks' gestation by her last menstrual period presents with sudden severe lower abdominal pain and shoulder tip pain. She has an intrauterine device in place. She is pale, sweaty and in severe pain. Blood pressure is 82/50 mmHg and heart rate 148/min. Urine pregnancy test is positive. Transvaginal ultrasound shows a 3.8 cm left adnexal mass with free fluid in the pouch of Douglas extending to the hepatorenal space. What is the most appropriate immediate management?
Options
- AIntravenous fluids, massive transfusion protocol and immediate surgery
- BIntramuscular methotrexate and review in 24 hours
- CRemove the IUD and reassess
- DCT abdomen to confirm the diagnosis before surgery
- EIntravenous morphine and reassess in 2 hours
Think it through before you read on. Which single option is best, and why are the other four wrong?
Show the answer and explanation
Answer
A. Intravenous fluids, massive transfusion protocol and immediate surgery
Why this is the right answer
This is a ruptured ectopic pregnancy with haemorrhagic shock. The features are a positive pregnancy test, an adnexal mass with no intrauterine pregnancy, and free fluid that has reached the hepatorenal space (Morison's pouch), which means a large volume of blood in the abdomen. Shoulder tip pain is referred pain from blood irritating the diaphragm. Her blood pressure of 82/50 mmHg and heart rate of 148/min show she has lost a great deal of blood.
Ruptured ectopic pregnancy is still a cause of maternal death in Australia. The only treatment that stops the bleeding is surgery. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists advises that a haemodynamically unstable woman with a suspected ectopic pregnancy goes directly to theatre.
Resuscitation and surgery happen at the same time, not one after the other. Two large-bore cannulas are inserted, blood is sent for group and crossmatch, the massive transfusion protocol is activated, and warmed fluids and then blood are given while theatre is prepared. Anti-D immunoglobulin is given afterwards if she is RhD negative.
Laparoscopic salpingectomy is the usual operation; a laparotomy is chosen if she is too unstable for laparoscopy or the surgeon lacks the necessary experience.
An intrauterine device does not cause ectopic pregnancy, but a pregnancy that occurs despite an IUD is much more likely to be ectopic. The device is removed at surgery.
Why the other options are wrong
- B
Methotrexate is only for stable women with a small, unruptured ectopic and low hCG; in shock it is dangerous.
- C
Removing the IUD does nothing for the haemorrhage; it is dealt with at surgery.
- D
CT wastes time and adds nothing; ultrasound plus shock is enough to go to theatre.
- E
A 2-hour delay in haemorrhagic shock could be fatal.
High-yield takeaway
Positive pregnancy test, empty uterus, free fluid and shock is a ruptured ectopic: resuscitate with blood and operate at once, no further imaging.
Reference: RANZCOG Clinical Guidance: Ectopic pregnancy (and Therapeutic Guidelines) (2023)
Common questions
What does shoulder tip pain mean in early pregnancy?
Blood in the abdomen irritating the diaphragm, referred along the phrenic nerve. It is a sign of a ruptured ectopic until proven otherwise.
When is methotrexate appropriate for an ectopic pregnancy?
Only in a stable woman with a small, unruptured ectopic, low and falling hCG, no fetal heartbeat and no significant free fluid.
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