A 32-year-old woman comes to the emergency department due to abdominal pain and nausea that began 2 days earlier but has become increasingly severe over the last 3 hours. The patient has passed several vaginal blood clots in the last hour. She has a history of irregular menstrual cycles and is not sure of the date of her last period. She was diagnosed with a bicornuate uterus 2 years ago during an infertility evaluation. The patient has no other medical conditions and has had no surgeries. BMI is 28 kg/m². Blood pressure is 90/56 mm Hg and pulse is 120/min. Abdominal examination shows guarding with decreased bowel sounds. Speculum examination shows moderate bleeding with clots from the cervix. A urine pregnancy test is positive. Transvaginal ultrasound reveals a gestational sac at the upper left uterine cornu and free fluid in the posterior cul-de-sac of the pelvis. Which of the following is the best next step in management of this patient?

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11ec25c8_da29_290a_bc81_f3c142f7bebd_MD0003_00 This patient with an acute abdomen (eg, severe pain, guarding) likely has hemoperitoneum from a ruptured ectopic pregnancy. Although most ectopic pregnancies implant in the ampulla of the fallopian tube, implantation occasionally occurs in the upper outer corners of the uterus (ie, cornua), where the uterine wall meets the proximal (ie, interstitial) fallopian tubes; these are known as cornual or interstitial ectopic pregnancies. Specific risk factors for cornual ectopic pregnancies include uterine anomalies (eg, bicornuate or unicornuate uterus) and in vitro fertilization. interstitial ectopic pregnancies bicornuate or unicornuate uterus The cornual region receives an abundant blood supply from both the uterine and the ovarian vessels; therefore, rupture in this area often leads to life-threatening intraabdominal hemorrhage, as well as heavy vaginal bleeding. Because blood is highly irritating to the peritoneum, patients with hemoperitoneum develop peritoneal inflammation and severe, diffuse abdominal pain. This accumulation of blood can often be seen on ultrasound as free fluid in the posterior cul-de-sac. Patients with hemoperitoneum and hemodynamic instability (eg, hypotension, tachycardia) require emergency surgical exploration to remove the ectopic pregnancy and achieve hemostasis. (Choice A) Dilation and curettage removes uterine contents and can be performed for a spontaneous abortion (eg, inevitable, septic), which may present with abdominal pain and vaginal bleeding. However, spontaneous abortions do not cause hemoperitoneum (eg, pelvic free fluid). (Choice B) Methotrexate is a treatment option in patients with an early, unruptured ectopic pregnancy. Ruptured ectopic pregnancy is a contraindication to its use. (Choice C) Misoprostol causes cervical dilation and myometrial contraction to expel intrauterine contents. Therefore, it can be used to treat spontaneous abortions. It is not an effective treatment for ectopic pregnancy and is not used in patients who are hemodynamically unstable. (Choice D) A quantitative β-hCG level would not change management in this patient with a cornual ectopic pregnancy; regardless of the level, she requires emergency surgery because she is hemodynamically unstable. In contrast, a patient treated medically with methotrexate requires serial β-hCG levels until they become undetectable to ensure that treatment is complete and there is no longer a risk for ectopic rupture. Educational objective: Cornual ectopic pregnancies (ie, pregnancy implantation in the upper outer corner of the uterine fundus) are highly vascular, and rupture can cause life-threatening intraabdominal hemorrhage. Hemodynamically unstable patients with hemoperitoneum due to a ruptured ectopic pregnancy require emergency surgical exploration. References: Cornual pregnancy: management and subsequent fertility. (http://www.ncbi.nlm.nih.gov/pubmed/26678164) Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/25156020)

A 32-Year-Old Woman Comes to the Emergency Department Due to Abdominal