A 28-year-old G2P1 woman presents with right lower quadrant pain and light vaginal spotting at 7 weeks amenorrhea. She has a history of chlamydial pelvic inflammatory disease. Serum β-hCG is 4,200 mIU/mL. Transvaginal ultrasound shows an empty uterus with a thin pseudosac, a 2.5 cm right adnexal heterogeneous mass, and free fluid in the cul-de-sac. The structure marked **B** in the diagram—the right adnexal tubal ring—is identified as the site of pregnancy implantation. Which of the following is the most appropriate IMMEDIATE management for this patient?

Why Laparoscopic salpingectomy is right

This patient has a confirmed ectopic pregnancy with a β-hCG of 4,200 mIU/mL (well above the discriminatory zone of 1,500–2,000 mIU/mL), a tubal mass >3.5 cm (2.5 cm is borderline but combined with free fluid in the cul-de-sac suggests imminent or actual rupture risk), and free intraperitoneal fluid. Although the patient is hemodynamically stable, the presence of free fluid in the cul-de-sac raises concern for rupture or hemorrhage. The tubal ring structure marked B represents the site of implantation within the fallopian tube. According to ACOG Bulletin 193 and Williams Obstetrics, emergency surgical intervention (laparoscopic salpingectomy) is indicated for patients with signs of intraperitoneal hemorrhage (evidenced by free fluid) or when the ectopic mass approaches or exceeds 3.5 cm. Salpingectomy is preferred over salpingostomy when the contralateral tube is healthy, as it eliminates the risk of persistent trophoblast and avoids the need for prolonged post-operative β-hCG monitoring.

Why each distractor is wrong

ACOG Bulletin 193; Williams Obstetrics 26e Ch 19