Ectopic pregnancy — suspected rupture

PLAB 2 & PRES 3 · obs-gyn · hard · 8 minutes

Candidate brief

You are an FY2 doctor/SHO in the Emergency Department. Ms Laura Brennan, 31, presents with worsening lower abdominal pain, vaginal bleeding and dizziness. She had a positive home pregnancy test 2 weeks ago. Assess her urgently, explain your likely diagnosis and initiate an appropriate emergency management and escalation plan. Verbalise any examinations, investigations and immediate treatment you would undertake.

What examiners look for

Consider ectopic pregnancy in any person of reproductive potential presenting with abdominal or pelvic pain, vaginal bleeding, dizziness, syncope, gastrointestinal symptoms or collapse. Typical features include unilateral lower abdominal pain, vaginal bleeding, amenorrhoea, shoulder-tip pain, dizziness and fainting. Vaginal bleeding may be light despite significant internal bleeding. Do not rely on risk factors. Ectopic pregnancy can occur without a previous ectopic pregnancy, pelvic infection, tubal surgery or fertility treatment. Haemodynamic instability, pallor, tachycardia, hypotension, guarding, rebound tenderness or collapse suggest rupture and internal bleeding. Use an immediate ABCDE approach. Obtain senior O&G help, monitoring, large-bore IV access, blood tests, crossmatch and early anaesthetic and theatre involvement. Transvaginal ultrasound is the first-line imaging test when the patient is stable enough. Do not delay urgent surgery in an unstable patient while waiting for ultrasound, serial hCG or other tests. A single serum hCG result cannot reliably identify where the pregnancy is located. Interpret it with symptoms, observations and ultrasound findings. Expectant management and methotrexate are unsuitable when the patient is unstable, rupture is suspected or significant pain or haemoperitoneum is present. Explain compassionately that an ectopic pregnancy cannot safely continue and that emergency surgery may be required. Avoid making premature promises about preserving the fallopian tube or future fertility. Offer pregnancy-loss and bereavement support after immediate safety needs have been addressed.

Guideline references

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