Ruptured Ectopic Pregnancy (right fallopian tube)

Ruby is a 23 y/o female presenting with right lower quadrant abdominal pain x 1 day.

 

History elements (these also indicate the questions that should be asked)

• Pain is in RLQ, continuous, sharp, 8/10, woke patient up from sleep, nothing makes it better or worse, non-radiating. This pain never happened before. Pain started out as 5/10 in the morning and suddenly increased to 8/10 2 hours ago.
• No past medical history, no surgical history, no allergies, doesn’t take any medications
• Nausea
• No vomiting, diarrhea, or constipation
• LMP 5 weeks prior, patient normally has irregular periods
• No dysuria, hematuria, vaginal discharge, flank pain, polyuria, genital lesions/masses
• Sexually active with one partner, uses barrier protection, last time 2 weeks ago
• No history of STI (never tested)
• No fever, chills, night sweats, joint pain, lymphadenopathy
• No SOB, chest pain, dizziness, syncope
• Weakness for 1 hour
• No recent trauma, falls, injuries

 

Physical Exam (also indicates what procedures should be done)

• Vital signs: BP: 98/54  HR: 122  RR: 24  SpO2: 98% room air   T: 37.8 C oral
• General: alert to person, place, time. Appears in pain, mild distress, diaphoretic.
• Skin: pale, cool, clammy, non-icteric. No scars, lesions, tattoos, rashes. No nail clubbing or pitting.
• Abdominal: abdomen appears non-distended, with no scars, masses or pulsations. Bowel sounds hypoactive but present in all quadrants. No bruits noted. Abdomen feels rigid, with 10/10 pain to palpation in RLQ, rebound tenderness, negative Rovsing/Obturator/Psoas signs. No hepatosplenomegaly.
• Cardiovascular: normal S1, S2 with PMI in 5th ICS midclavicular line. Carotid pulses 2+ bilaterally without bruits. No S3, S4, no murmurs, no friction rubs.
• Genitourinary: external genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema. Blood seen in vaginal vault. Cervix nulliparous, pink, without lesions. Positive cervical motion tenderness. Uterus anterior, midline, smooth, tender, and mildly enlarged. Adnexal and suprapubic tenderness present. No inguinal adenopathy.
• Rectal: rectovaginal wall intact. No external hemorrhoids, ulcers, sinus tracts, anal fissures, inflammation, excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOBT negative.
• Peripheral vascular: extremities cool and pale. Pulses are 1+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, or edema noted bilaterally. Capillary refill < 2 seconds throughout. No stasis changes or ulcerations noted.

 

Differential Diagnosis

• Ruptured ectopic pregnancy
  • Lower abdominal pain, vitals signs indicative of shock, and blood in the vaginal vault indicate a hemorrhagic process which is further confirmed with hCG level and transvaginal ultrasound
• Ruptured appendicitis
  • Initial presentation of right lower quadrant abdominal pain with rebound tenderness indicates appendicitis with rupture
• Ovarian torsion
  • Must rule out in female of child-bearing age with sharp lower abdominal pain
• Pelvic inflammatory disease
  • Abdominal pain with blood in vaginal vault, as well as cervical motion tenderness on exam and unknown STI history since patient never got tested
• Spontaneous abortion
  • Vaginal bleeding and abdominal pain in female of child-bearing age with LMP 5 weeks ago

 

Tests:

• Urine pregnancy test
  • positive
• Blood hCG level
  • 6000 mIU/mL
• CBC
  • WBC: 6,000
  • RBC: 4.1
  • Hgb: 7
  • Hct: 25
  • MCV: 84
  • MCH: 24
  • MCHC: 33
  • Platelets: 160,000
  • RDW: 11.9%
• Type and screen
  • O negative
• CMP
  • Within normal limits
• transvaginal ultrasound

• echogenic fluid (consistent with blood) in the pelvic cul-de-sac
• Absent intrauterine gestation

 

Treatment

• Salpingectomy
• IV fluids
• Vasopressors
• Blood transfusion

Pt. counseling

• Advise patient that a history of ectopic pregnancy and tubal surgery is a risk factor for future ectopic pregnancies

• Advise patient to get STI testing as STIs can lead to pelvic inflammatory disease and subsequently increase risk for ectopic pregnancy
• Advise of use of IUD for contraception if patient is interested in contraception other than barrier protection, as it has a lower rate of ectopic pregnancy
• Invite questions and use teach back to make sure that the patient has understood the important points