A 28-year-old woman presents to the emergency department with acute lower abdominal pain and vaginal spotting for 2 days. She reports a positive home pregnancy test 1 week ago. Her last menstrual period was 6 weeks ago. On examination, she is pale, heart rate 110/min, blood pressure 100/60 mmHg, and has severe left lower quadrant tenderness with rebound. Serum β-hCG is 8,500 mIU/mL. Transvaginal ultrasound shows an empty uterine cavity and free fluid in the pouch of Douglas. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis: Ruptured Ectopic Pregnancy **Key Point:** This patient has clinical and radiological evidence of a ruptured ectopic pregnancy with haemodynamic instability — a surgical emergency requiring immediate intervention. ### Diagnostic Features Present - **Empty uterine cavity** on transvaginal ultrasound at 6 weeks gestation - **Free fluid in pouch of Douglas** (haemoperitoneum) - **Haemodynamic instability:** Tachycardia (110/min), hypotension (100/60 mmHg), pallor - **Clinical signs:** Severe rebound tenderness, acute presentation - **Elevated β-hCG (8,500 mIU/mL)** consistent with early pregnancy ### Management Algorithm ```mermaid flowchart TD A[Ectopic Pregnancy Confirmed]:::outcome --> B{Haemodynamically Stable?}:::decision B -->|No - Unstable| C[Ruptured Ectopic]:::urgent B -->|Yes - Stable| D{β-hCG <5000 & No Rupture Signs?}:::decision C --> E[Immediate Laparotomy]:::action D -->|Yes| F[Medical or Laparoscopic Management]:::action D -->|No| G[Laparoscopy ± Conservative Surgery]:::action E --> H[Salpingectomy or Salpingostomy]:::action ``` **High-Yield:** Ruptured ectopic pregnancy with haemodynamic instability is a **surgical emergency**. Laparotomy is the standard approach when the patient is unstable; laparoscopy is reserved for stable patients. ### Why Immediate Laparotomy? 1. **Haemodynamic instability** precludes safe laparoscopy 2. **Massive haemoperitoneum** requires rapid access and control of bleeding 3. **Time-critical:** Risk of exsanguination 4. **Definitive treatment:** Salpingectomy (if recurrent ectopic risk) or salpingostomy (if fertility desired and anatomy permits) **Clinical Pearl:** In a haemodynamically unstable patient, do not delay surgery for further imaging or diagnostic laparoscopy. The clinical picture (empty uterus + free fluid + instability) is diagnostic. **Warning:** ~~Methotrexate is contraindicated in ruptured ectopic pregnancy~~ — it is used only in stable, unruptured cases with β-hCG <5,000 and no rupture signs. Expectant management is also inappropriate when rupture is evident.