A 29-year-old woman with 8 weeks amenorrhoea collapses in the emergency department with severe abdominal pain and pain referred to the left shoulder tip. She has pulse 122 per minute, blood pressure 84/50 mmHg, marked abdominal distension with guarding, and cervical motion tenderness. Urine pregnancy test is positive. What is the immediate next step?

• A Transvaginal ultrasound before any intervention
• B Immediate laparotomy via midline incision ✓
• C Single-dose methotrexate 50 mg/m2 intramuscularly
• D Diagnostic culdocentesis

Explanation

Haemodynamic collapse with peritonism, shoulder tip pain from diaphragmatic irritation by blood, and a positive pregnancy test indicates ruptured ectopic with massive haemoperitoneum. Resuscitation runs parallel with immediate laparotomy to control bleeding; delaying for ultrasound risks death from haemorrhage. Methotrexate is contraindicated in rupture. Culdocentesis is an obsolete test and would only confirm blood already clinically evident. Salpingectomy is usually performed once the tube is visualised at surgery.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.