Management of Ruptured Ectopic Pregnancy in the Emergency Department
A patient with a ruptured ectopic pregnancy requires immediate hemodynamic stabilization, urgent surgical consultation, and preparation for emergency laparotomy or laparoscopy—medical management with methotrexate is absolutely contraindicated in the setting of rupture. 1, 2
Immediate Resuscitation and Stabilization
- Establish large-bore IV access (two lines minimum) and begin aggressive fluid resuscitation with crystalloids while preparing for blood product transfusion 3, 4
- Obtain type and crossmatch for at least 2-4 units of packed red blood cells immediately, as massive hemorrhage can occur rapidly 5, 6
- Monitor vital signs continuously for signs of hemodynamic instability including hypotension, tachycardia, and altered mental status 3, 7
- Activate massive transfusion protocol if the patient shows signs of hemorrhagic shock or has evidence of significant hemoperitoneum 6, 4
Diagnostic Confirmation
While resuscitation proceeds, confirm the diagnosis if not already established:
- Bedside transvaginal ultrasound looking for free fluid in the pelvis/abdomen (hemoperitoneum), empty uterus, and adnexal mass 3, 5
- Quantitative β-hCG level should be obtained but should never delay surgical intervention in an unstable patient 3, 7
- Complete blood count to assess degree of anemia and guide transfusion needs 1, 4
Surgical Management
Immediate surgical intervention is the only definitive treatment for ruptured ectopic pregnancy:
- Contact obstetrics/gynecology immediately for emergency surgical consultation—do not delay for additional testing if the patient is unstable 7, 4
- Laparoscopy is preferred in hemodynamically stable patients, but laparotomy should be performed without hesitation in unstable patients or when massive hemoperitoneum is suspected 5, 8
- Salpingectomy is generally preferred over salpingostomy in the setting of rupture, as tube salvage procedures carry significant risk of persistent trophoblastic tissue and re-rupture 8
Critical Contraindications
Methotrexate is absolutely contraindicated in ruptured ectopic pregnancy and should never be considered, as this is a surgical emergency requiring immediate operative intervention 1, 2. The evidence shows that 38% of patients with ruptured ectopic pregnancy required surgery even when initially considered for medical management 1.
Additional Considerations
- Administer Rh immunoglobulin (RhoGAM) to all Rh-negative patients with ectopic pregnancy to prevent alloimmunization 2, 3
- Prepare for potential complications including coagulopathy in cases of massive hemorrhage, which may require fresh frozen plasma and platelets 6
- Do not wait for operating room availability if the patient is deteriorating—consider emergency department thoracotomy or immediate transfer to the OR 4
Common Pitfalls to Avoid
- Never attempt expectant management or methotrexate therapy in a patient with any signs of rupture, including significant free fluid on ultrasound, peritoneal signs, or hemodynamic instability 1, 2, 7
- Do not delay surgery for additional imaging such as CT scan if clinical suspicion is high and the patient is unstable 3, 4
- Avoid undertransfusion—patients with ruptured ectopic pregnancy can have massive intra-abdominal bleeding (cases report finding liters of blood in the peritoneal cavity) 5, 6