From the Guidelines
The patient requires immediate surgical intervention via laparotomy due to signs and symptoms concerning for a ruptured ectopic pregnancy, which is a surgical emergency. The patient presents with severe right lower quadrant pain, nausea, vomiting, guarding, and rebound tenderness, suggesting peritoneal irritation from intra-abdominal bleeding. The ultrasound findings of a right lower quadrant mass without an intrauterine gestational sac, combined with a missed period (LMP 3 weeks ago), strongly support the diagnosis of a ruptured ectopic pregnancy, as a study published in the Journal of the American College of Radiology in 2024 1 suggests that the absence of an intrauterine pregnancy when the b-hCG level is >3,000 mIU/mL should be strongly suggestive of an ectopic pregnancy. Key points to consider in this diagnosis include:
- The high specificity of adnexal findings suggestive of ectopic pregnancy, including the classic “tubal ring” 1
- The sensitivity and positive predictive value (PPV) for ectopic pregnancy in cases evaluated with TVUS and when serum b-hCG level was <2,000 mIU/mL was 34.3% and 80.4% compared with definite diagnosis at follow-up by gynecology service (sensitivity of 75.9% and PPV of 91.5%) 1
- TVUS as a screening test for ectopic pregnancy demonstrated a 99% sensitivity and 84% specificity in a prospective study of 1,427 patients with b-hCG levels >1,500 IU/L 1 Laparotomy is indicated for hemodynamically unstable patients or those with signs of rupture to control bleeding and remove the ectopic pregnancy. Other options, such as methotrexate (MTX) or a D&C, would be inappropriate in this case as they are only used for stable, unruptured ectopic pregnancies or would not address the ectopic pregnancy in the fallopian tube, respectively. The urgency of this situation requires immediate surgical intervention to prevent further hemorrhage and potential mortality, as supported by the 2024 study published in the Journal of the American College of Radiology 1.
From the Research
Patient Presentation
The patient presents with severe right lower quadrant (RLQ) abdominal pain, nausea, vomiting, guarding, and rebound tenderness, with a last menstrual period (LMP) 3 weeks ago. A pelvic ultrasound shows a right lower quadrant mass without an intrauterine gestational sac.
Diagnostic Considerations
- Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established 2
- The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa 2
- In this case, the presence of a right lower quadrant mass without an intrauterine gestational sac on ultrasound suggests a possible ectopic pregnancy
Treatment Options
- Medical management with intramuscular methotrexate is a safe and effective alternative to surgery for the treatment of unruptured ectopic pregnancy 3, 2
- Surgical management via salpingostomy or salpingectomy may be necessary in cases of rupture or hemodynamic instability 2
- Expectant management may be considered in asymptomatic patients with a serum hCG titer <1,000 IU/l that is falling 4
Next Steps
- Given the patient's symptoms and ultrasound findings, a diagnosis of ectopic pregnancy should be considered and further evaluation and treatment should be pursued 2, 5
- The patient should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management 2
- Laparoscopy may be considered for diagnosis and treatment of ectopic pregnancy, as it is a safe and effective approach with shorter hospital stay and faster recovery 6