CCS Case: Ectopic Pregnancy — Ruptured

Case: Ectopic Pregnancy — Ruptured

Clinical Setup

• Presentation: 27-year-old female, 7 weeks by last menstrual period, with sudden severe left lower quadrant pain, syncope, and vaginal spotting. BP 88/54, HR 122, pale, peritoneal signs.
• Location: Emergency Department.

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring, BP q15min.
   • 2 large-bore IVs, Normal saline 0.9% IV wide open / 1000 mL bolus stat.
   • NPO stat, continuous vitals, bed rest.
2. Focused Exam (Minute 1–2):
   • Abdominal exam (rebound, guarding), pelvic exam (cervical motion tenderness, adnexal mass/tenderness) — gentle exam.
3. Diagnostics (Minute 2–5):
   • Urine pregnancy test stat, quantitative serum beta-hCG stat.
   • CBC stat, Type and Crossmatch, PT/INR, PTT.
   • Transvaginal pelvic ultrasound stat (empty uterus, adnexal mass, free fluid in cul-de-sac).
4. Therapeutics & Consultation (Minute 5–10):
   • OB/GYN consult stat; ruptured ectopic with instability = emergent laparoscopic/laparotomy salpingectomy or salpingostomy.
   • Transfuse packed RBCs for hypotension/anemia; Rh(D) immune globulin (RhoGAM) if Rh-negative.
   • Stable unruptured ectopic alternative: Methotrexate IM only if hemodynamically stable, no rupture, and criteria met — NOT for this unstable case.
   • Advance clock 15 min; re-examine vitals and abdominal exam.
5. Disposition (Minute 10–15):
   • Transfer to OR emergently, then post-op gynecology ward.
   • Serial hemoglobin checks post-operatively.
6. Final 2 Minutes:
   • Counsel on future ectopic risk, early ultrasound in next pregnancy, contraception options, STI screening (PID risk factor).
   • Schedule OB/GYN follow-up within 1 week with serial beta-hCG to zero.