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Collapse in early pregnancy
A 27-year-old woman with a history of pelvic inflammatory disease has had 7 weeks of amenorrhea and light vaginal bleeding. She develops sudden left lower abdominal pain and collapses. BP is 82/50 mm Hg and her urine pregnancy test is positive.
Step 1 of 4
Where would bedside ultrasound most likely show free fluid first?
Correct answer: B
The rectouterine pouch (of Douglas) is the lowest part of the female peritoneal cavity when upright or supine, so blood collects there first. Pregnant + pain + free fluid in the pouch = ruptured ectopic until proven otherwise.
Show answer
B
The rectouterine pouch (of Douglas) is the lowest part of the female peritoneal cavity when upright or supine, so blood collects there first. Pregnant + pain + free fluid in the pouch = ruptured ectopic until proven otherwise.
Step 2 of 4
What is the most common site of an ectopic pregnancy?
Correct answer: B
About 95% of ectopics are tubal, most in the ampulla — the widest part and the usual site of fertilization (see uterine tubes).
Show answer
B
About 95% of ectopics are tubal, most in the ampulla — the widest part and the usual site of fertilization (see uterine tubes).
Step 3 of 4
Which part of her history is a risk factor?
Correct answer: B
Prior PID scars the tubes. Other risk factors are a prior ectopic, tubal surgery or ligation, pregnancy with an IUD in place, assisted reproduction and smoking.
Show answer
B
Prior PID scars the tubes. Other risk factors are a prior ectopic, tubal surgery or ligation, pregnancy with an IUD in place, assisted reproduction and smoking.
Step 4 of 4
What is the most appropriate management?
Correct answer: B
A ruptured ectopic with hemodynamic instability needs surgery. Methotrexate is only for stable, unruptured ectopics that meet criteria. Give anti-D if she is Rh-negative.
Show answer
B
A ruptured ectopic with hemodynamic instability needs surgery. Methotrexate is only for stable, unruptured ectopics that meet criteria. Give anti-D if she is Rh-negative.
Key points
- Positive pregnancy test + pain + free fluid in the rectouterine pouch → ruptured ectopic.
- Ampulla is the commonest site; prior PID is a key risk factor.
- Unstable or ruptured → surgery; stable and unruptured → methotrexate if criteria are met.
Study: Rectouterine pouch, Uterine tubes, Uterus