Model Answer
0 min readIntroduction
Ectopic pregnancy is a potentially life-threatening condition where a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. It’s a significant cause of maternal morbidity and mortality, particularly when ruptured. The clinical presentation can be subtle, making early diagnosis crucial. A 25-year-old woman presenting with amenorrhea, acute abdominal pain, fainting, tachycardia, hypotension, and pelvic tenderness strongly suggests a ruptured ectopic pregnancy, requiring immediate medical attention. This answer will detail the diagnosis, investigations, and management of such a case.
(i) Most Likely Diagnosis
The most likely diagnosis is a ruptured ectopic pregnancy. The combination of 10 weeks amenorrhea (suggesting pregnancy), acute lower abdominal pain, fainting (suggesting hypovolemic shock due to internal bleeding), tachycardia, hypotension, and pelvic tenderness is highly suggestive of this condition. The fainting and hemodynamic instability (tachycardia and hypotension) indicate significant blood loss, pointing towards rupture.
(ii) Investigations
A rapid and focused investigation protocol is essential. The following investigations should be performed:
- Complete Blood Count (CBC): To assess the degree of anemia and estimate blood loss.
- Blood Group and Rh Typing: Essential for potential blood transfusion and to determine the need for anti-D immunoglobulin if the patient is Rh-negative.
- Serum Beta-hCG (β-hCG): Quantitative β-hCG levels help assess the viability of the pregnancy and monitor treatment response. Levels should be abnormally low for gestational age in ectopic pregnancy.
- Serum Progesterone: Low progesterone levels (<5 ng/mL) are suggestive of a non-viable pregnancy.
- Transvaginal Ultrasound (TVUS): This is the primary imaging modality. It can visualize the gestational sac, confirm its location (extrauterine), and identify free fluid in the peritoneal cavity (indicating rupture).
- Culdocentesis: If TVUS is inconclusive or unavailable, culdocentesis (aspiration of fluid from the pouch of Douglas) can detect the presence of intraperitoneal blood. However, it is less commonly used now with the widespread availability of TVUS.
- Laparoscopy: Diagnostic laparoscopy may be necessary if the diagnosis remains uncertain after initial investigations, or if the patient is hemodynamically unstable and requires immediate surgical intervention.
(iii) Management
Management is guided by the patient’s hemodynamic stability and the findings of investigations. The key points are:
- Resuscitation: This is the priority.
- Establish intravenous (IV) access with two large-bore catheters.
- Administer crystalloid solutions (e.g., Ringer’s lactate) to restore intravascular volume.
- Monitor vital signs closely (blood pressure, heart rate, oxygen saturation).
- Consider blood transfusion if the patient is significantly anemic.
- Administer oxygen.
- Surgical Intervention: Most ruptured ectopic pregnancies require surgical intervention.
- Laparoscopy: The preferred approach if the patient is hemodynamically stable. Salpingectomy (removal of the affected fallopian tube) or salpingostomy (incision into the tube to remove the ectopic pregnancy) can be performed.
- Laparotomy: Indicated in cases of significant hemodynamic instability, extensive hemoperitoneum, or if laparoscopic access is difficult.
- Medical Management (Limited Role in Rupture): While medical management (methotrexate) is an option for stable, unruptured ectopic pregnancies, it is generally not appropriate for ruptured cases due to the risk of ongoing bleeding.
- Postoperative Care:
- Continue monitoring vital signs and blood loss.
- Administer analgesics for pain control.
- Monitor hemoglobin levels and transfuse blood as needed.
- Administer anti-D immunoglobulin if the patient is Rh-negative.
- Counsel the patient regarding future fertility and the risk of recurrent ectopic pregnancy.
Important Considerations: Early involvement of an obstetrician and anesthesiologist is crucial. A multidisciplinary approach is essential for optimal patient care.
Conclusion
Ruptured ectopic pregnancy is a life-threatening obstetric emergency demanding prompt recognition and intervention. Prioritizing hemodynamic stabilization, followed by definitive surgical management, is paramount. Thorough investigations are essential for accurate diagnosis, and comprehensive postoperative care is crucial for ensuring optimal patient recovery and future reproductive health. Continued vigilance and improved access to early pregnancy diagnostic services are vital for reducing maternal morbidity and mortality associated with this condition.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.