A 25-year-old woman presents to the emergency department with 5 weeks amenorrhea and syncope. On examination, she is tachycardic (pulse 120/min), hypotensive (80/50 mmHg), and has diffuse abdominal tenderness with guarding. Transvaginal ultrasound shows a large amount of free fluid in the pouch of Douglas and an empty uterus. Serum β-hCG is 3,500 mIU/mL. What is the most appropriate next step?

• A Administer single-dose intramuscular methotrexate
• B Perform diagnostic laparoscopy
• C Repeat β-hCG in 48 hours to confirm the diagnosis
• D Proceed to emergency laparotomy with fluid resuscitation ✓

Explanation

This patient has a ruptured ectopic pregnancy with hemodynamic instability and hemoperitoneum. Emergency laparotomy with simultaneous aggressive fluid resuscitation is indicated. Methotrexate is contraindicated in hemodynamically unstable patients and those with rupture. Laparoscopy may be feasible in stable patients but laparotomy is preferred here due to the need for rapid hemorrhage control. Delaying surgery to repeat β-hCG is inappropriate in a shocked patient with clear signs of rupture.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.