A 28-year-old woman presents to the emergency department with acute lower abdominal pain and vaginal bleeding for 2 days. She reports a missed period 6 weeks ago. On examination, she is hemodynamically unstable (BP 90/60, HR 110/min), with severe right lower quadrant tenderness and cervical motion tenderness. Urine β-hCG is positive. Transvaginal ultrasound shows no intrauterine gestational sac, free fluid in the pelvis, and a complex mass in the right adnexa measuring 3 cm. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis and Rationale **Key Point:** This patient has a ruptured ectopic pregnancy with hemodynamic instability and signs of hemoperitoneum — a surgical emergency requiring immediate intervention. ### Why Emergency Laparotomy with Salpingectomy? The clinical presentation mandates surgical intervention: - **Hemodynamic instability** (BP 90/60, HR 110) indicates active bleeding and shock - **Free fluid on ultrasound** confirms hemoperitoneum - **Adnexal mass 3 cm** with no intrauterine sac confirms ectopic pregnancy - **Acute presentation** (2 days of bleeding) suggests rupture **High-Yield:** In a hemodynamically **unstable** ectopic pregnancy, laparotomy (not laparoscopy) is indicated because: 1. Faster access and hemorrhage control 2. Ability to manage massive transfusion if needed 3. Salpingectomy is preferred over salpingostomy in emergency settings due to lower recurrence risk and reduced need for follow-up β-hCG monitoring ### Management Algorithm for Ectopic Pregnancy ```mermaid flowchart TD A[Confirmed ectopic pregnancy]:::outcome --> B{Hemodynamically stable?}:::decision B -->|No| C[Hemodynamic instability/rupture]:::urgent C --> D[Emergency laparotomy]:::action D --> E[Salpingectomy]:::action B -->|Yes| F{β-hCG <5000 + mass <3.5 cm?}:::decision F -->|Yes| G[Medical management: Methotrexate]:::action F -->|No| H[Surgical: Laparoscopy ± salpingostomy]:::action E --> I[Hemostasis + transfusion]:::action G --> J[Serial β-hCG monitoring]:::action H --> J ``` **Clinical Pearl:** Salpingectomy is the gold standard in emergency ruptured ectopic pregnancy because it eliminates the source of bleeding immediately and reduces the 10–25% recurrence risk seen with salpingostomy. **Mnemonic:** **RUSH** — **R**uptured, **U**nstable, **S**urgery, **H**ysterectomy/salpingectomy. ## Why Other Options Are Wrong | Option | Why Incorrect | |--------|---------------| | Methotrexate | Medical management is contraindicated in hemodynamically unstable patients; it takes 7–14 days to work and patient needs immediate hemorrhage control. | | Laparoscopy + salpingostomy | Laparoscopy is inadequate for massive hemorrhage; salpingostomy increases recurrence risk (10–25%) and requires prolonged β-hCG follow-up — unacceptable in acute rupture. | | Observation with serial β-hCG | Expectant management is contraindicated in unstable patients with rupture and hemoperitoneum; delays definitive treatment and risks maternal death. | [cite:Jeffcoate's Principles of Gynaecology 8e Ch 12]