A 26-year-old woman presents with abdominal pain. It started suddenly 2 h ago and was initially in the lower abdomen but is now generalized. She feels nauseated and dizzy, especially when she sits up. She also feels as if she has bruised her shoulder. She has not noticed any vaginal bleeding or discharge, and there are no bowel or urinary symptoms.
She does not keep a record of her period dates but thinks the last one was about a month ago. She has a regular partner and says that they often forget to use a condom.
She had a termination 3 years ago. She was diagnosed with chlamydia when she was admitted to hospital at the age of 19 years with a pelvic infection.
There is no other medical history of note.
On examination she is pale and looks unwell. She is intermittently drowsy. She is lying flat and still on the bed. The temperature is 35.9°C, pulse 120/min and blood pressure 95/50 mmHg. Peripherally she is cool and the hands are clammy. She is generally slim but the abdomen is symmetrically distended. There is generalized tenderness on light palpa- tion, with rebound tenderness and guarding. There are no obviously palpable masses and vaginal examination has not been carried out.
Urinary pregnancy test: positive
· What is the likely diagnosis?
· How would you manage the patient?
Any woman who is unwell with abdominal pain should be assumed to have a ruptured ectopic pregnancy. In this case there are risk factors and the symptoms of dizziness, nau- sea, severe abdominal pain and shoulder pain are classical of haemoperitoneum. The examination findings of cool and clammy peripheries, a distended abdomen, tachycardia and hypotension also suggest the clinical diagnosis and a positive pregnancy test confirms this.
Young women tend to compensate for hypovolaemia, and the fact that this woman is now cool and clammy with hypotension suggests that she is gravely unwell and should be transferred for definitive management without delay.
Although the haemoglobin does not seem dramatically reduced, it is likely that on repeat testing it may now be extremely low.
The anaesthetist, theatre staff and senior gynaecologist should be alerted immediately and the woman transferred to theatre for surgery. An ultrasound is not necessary and would increase the threat to this woman by increasing the delay in reaching theatre.
Ruptured ectopic pregnancy is still the leading cause of maternal death in early preg- nancy, and doctors must be alert to the occasional presentation with life-threatening haemorrhage, as in this case.
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