A 25-year-old primigravida presents to the emergency department with sudden-onset severe lower abdominal pain and syncope at 6 weeks of gestation. Pulse is 126/min, BP is 84/50 mm Hg. Abdominal examination reveals diffuse tenderness with shifting dullness. Transvaginal ultrasound shows a large amount of free fluid in the pouch of Douglas and an empty uterus. What is the most appropriate immediate management?

• A Serial β-hCG monitoring every 48 hours
• B Transvaginal ultrasound-guided methotrexate injection
• C Diagnostic laparoscopy after hemodynamic stabilization
• D Urgent laparotomy with salpingectomy ✓

Explanation

Hemodynamic instability with signs of hemoperitoneum (shifting dullness, syncope, hypotension) in a patient with ultrasound findings consistent with ruptured ectopic pregnancy mandates immediate laparotomy. Laparoscopy is reserved for hemodynamically stable patients. Methotrexate and expectant management are contraindicated in ruptured ectopic pregnancy.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.