What is the most appropriate next step in managing a 25-year-old woman with sudden onset of diffuse abdominal pain, nausea, tachycardia, hypotension, and right adnexal tenderness, with pending pregnancy test results?

From the Guidelines

The most appropriate next step in management for this patient is to administer intravenous normal saline fluids (option C). This 25-year-old woman presents with signs of hypovolemic shock (tachycardia, hypotension, pallor, diaphoresis) and has risk factors for ectopic pregnancy (inconsistent oral contraceptive use, multiple sexual partners, missed period). While the pregnancy test is pending, immediate fluid resuscitation is critical to stabilize her hemodynamic status, as emphasized by the Surviving Sepsis Campaign guidelines 1. The patient's vital signs indicate compensatory mechanisms are active but failing, and fluid resuscitation will help maintain organ perfusion while the diagnostic workup continues. Her normal hemoglobin level (13 g/dL) suggests that significant blood loss may have occurred recently but hasn't yet affected her hemoglobin concentration. After initial fluid resuscitation, a pelvic ultrasound would be appropriate to evaluate for ectopic pregnancy, which is the most concerning diagnosis given her presentation, as suggested by the ACR Appropriateness Criteria for acute pelvic pain in the reproductive age group 1. Exploratory laparoscopy may be needed later but isn't the first step before stabilization. Blood transfusion isn't immediately indicated with her current hemoglobin level, and antibiotics or CT scan wouldn't address the urgent need for hemodynamic stabilization in this likely case of ruptured ectopic pregnancy. The use of intravenous fluids for resuscitation is critical in patients with ongoing sepsis, and the choice of fluid should be based on clinical endpoints, such as mean arterial pressure, skin color, and capillary refill, as well as urinary output 1. In this case, the administration of intravenous normal saline fluids is the most appropriate next step in management to stabilize the patient's hemodynamic status before further diagnostic workup and potential surgical intervention.

From the Research

Patient Assessment and Management

The patient presents with sudden onset of diffuse abdominal pain, nausea, and is sexually active with inconsistent use of oral contraceptive pills. Her last menstrual period was 6 weeks ago, and she is showing signs of hemodynamic instability (hypotension, tachycardia). Given her symptoms and history, ectopic pregnancy should be considered as a potential diagnosis 2, 3.

Diagnostic Approach

The first step in diagnosis is to confirm pregnancy, which is pending in this case. However, given the patient's instability, it is crucial to proceed with caution and consider the possibility of a ruptured ectopic pregnancy, which is a life-threatening emergency 2, 4.

Immediate Management

Given the patient's hemodynamic instability (low blood pressure, high pulse rate), the most appropriate next step would be to address her shock state. This involves:

• Administering intravenous fluids to stabilize her blood pressure and improve circulation 4.
• Considering the administration of blood products if there is evidence of significant blood loss, although her current hemoglobin level is within normal limits.

Diagnostic Imaging

Once the patient is stabilized, further diagnostic workup can be pursued. Given the suspicion of ectopic pregnancy, a pelvic ultrasound would be the most appropriate next imaging step to visualize the uterus and adnexa 2, 5, 3.

Key Considerations

• The patient's presentation with abdominal pain and hemodynamic instability warrants immediate attention to rule out a ruptured ectopic pregnancy.
• A negative pregnancy test does not entirely rule out ectopic pregnancy, especially in early stages or with sensitive tests 6.
• The definitive diagnosis of ectopic pregnancy can often be made with ultrasound, but serial beta human chorionic gonadotropin levels and clinical judgment are also crucial 2.

Next Steps

The most appropriate next step in management, given the information provided and the need to address the patient's immediate hemodynamic instability, is to:

• Administer intravenous normal saline fluids to stabilize her vital signs.
• Proceed with a pelvic ultrasound as soon as feasible to aid in diagnosis, considering her symptoms and risk factors for ectopic pregnancy.