A 29-year-old woman comes to the emergency department with lower abdominal pain that woke her up 7 hours ago and has not been relieved by acetaminophen. Movement and deep inspiration make the pain worse. The patient has no chronic medical conditions. She underwent a laparoscopic appendectomy at age 14. She is sexually active and uses condoms for contraception. The patient's last menstrual period was 5 weeks ago, but she has had intermittent vaginal spotting the last few days. She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs. The patient has no known drug allergies. Temperature is 37.2 C (99 F), blood pressure is 84/60 mm Hg, pulse is 124/min, and respirations are 18/min. Cardiac examination shows tachycardia with a normal rhythm; there are no murmurs. The lungs are clear to auscultation bilaterally. Bowel sounds are decreased, and the abdomen is diffusely tender and rigid, with rebound and guarding. Pelvic examination shows cervical motion tenderness and diffuse uterine and adnexal tenderness. Laboratory results are as follows: In addition to appropriate supportive care, which of the following is the best next step in management of this patient?

Question

A 29-year-old woman comes to the emergency department with lower abdominal pain that woke her up 7 hours ago and has not been relieved by acetaminophen.  Movement and deep inspiration make the pain worse.  The patient has no chronic medical conditions.  She underwent a laparoscopic appendectomy at age 14.  She is sexually active and uses condoms for contraception.  The patient's last menstrual period was 5 weeks ago, but she has had intermittent vaginal spotting the last few days.  She smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  The patient has no known drug allergies.  Temperature is 37.2 C (99 F), blood pressure is 84/60 mm Hg, pulse is 124/min, and respirations are 18/min.  Cardiac examination shows tachycardia with a normal rhythm; there are no murmurs.  The lungs are clear to auscultation bilaterally.  Bowel sounds are decreased, and the abdomen is diffusely tender and rigid, with rebound and guarding.  Pelvic examination shows cervical motion tenderness and diffuse uterine and adnexal tenderness.  Laboratory results are as follows:  In addition to appropriate supportive care, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bef2_66bb_8f63_83b368ea132d_MD0005_00 Patients with ectopic pregnancy (ie, pregnancy outside the uterus) have amenorrhea, irregular vaginal spotting, acute pelvic pain, and a positive pregnancy test. Risk factors include tobacco use, pelvic inflammatory disease, previous ectopic pregnancy, and prior pelvic surgery (eg, appendectomy). Patients with first-trimester bleeding should be evaluated for ectopic pregnancy because it is a significant cause of pregnancy-related death. ectopic pregnancy In reproductive-age women with possible ectopic pregnancy, initial evaluation includes a complete blood count, blood type and screen, and pregnancy test (eg, quantitative β-hCG). In hemodynamically unstable patients (eg, hypotension, tachycardia) with signs of hemoperitoneum (abdominal rigidity, rebound, guarding) and adnexal tenderness, ruptured ectopic pregnancy is diagnosed; the next step is immediate surgical intervention via emergency laparoscopy. In hemodynamically stable patients, pelvic ultrasound is performed, with surgery for those with hemoperitoneum. This hemodynamically unstable patient likely has a ruptured ectopic pregnancy and requires emergency laparoscopy. (Choice A) CT scan is not indicated in hemodynamically unstable pregnant patients who require immediate surgical intervention. It provides no diagnostic value because ruptured ectopic pregnancy is a clinical diagnosis confirmed during surgery. (Choice B) Culdocentesis, aspiration of peritoneal fluid through the posterior vaginal fornix, can be performed to examine peritoneal fluid contents (eg, blood). This patient's physical examination is consistent with hemoperitoneum, so culdocentesis is not indicated. (Choice D) In a normal pregnancy, the β-hCG level increases by at least 35% every 48 hours, and an intrauterine pregnancy usually becomes visible on transvaginal ultrasound at β-hCG levels >3,500 IU/L. In clinically stable patients, β-hCG levels <3,500 IU/L can be repeated in 48 hours. (Choice E) A complete blood count may be repeated to evaluate ongoing bleeding in clinically stable patients. This patient is hemodynamically unstable, has hemoperitoneum, and requires urgent surgical intervention rather than continued monitoring and observation. Educational objective: In hemodynamically unstable patients with hemoperitoneum, a positive pregnancy test is diagnostic for a ruptured ectopic pregnancy. Treatment is with emergency surgical intervention. References: Rupture of ectopic pregnancy with negative serum beta-hCG leading to hemorrhagic shock. (http://www.ncbi.nlm.nih.gov/pubmed/19155948) Ruptured ectopic pregnancy: risk factors for a life-threatening condition. (http://www.ncbi.nlm.nih.gov/pubmed/18762959)

A 29-Year-Old Woman Comes to the Emergency Department with Lower