Ruptured Ectopic Pregnancy

Ruptured ectopic pregnancy is an ectopic pregnancy that has burst through the tubal wall or other implantation site, causing intraperitoneal haemorrhage. It results from growth of trophoblast that erodes the vessels and wall. It is a surgical emergency and a leading cause of maternal death in the first trimester.

• Usually occurs at 6 to 10 weeks.
• Risk factors: previous ectopic, pelvic infection, tubal damage, intrauterine contraceptive device.
• Shock can develop within minutes.

Sudden severe lower abdominal pain, dizziness or collapse, shoulder tip pain and pallor follow a period of amenorrhoea. Examination shows tachycardia, hypotension, abdominal guarding and a bulging, tender pouch of Douglas.

• Pulse above 110 per minute, systolic below 90 mmHg.
• Distended abdomen with rebound.
• Vaginal bleeding may be minimal.
• Differential diagnosis: ruptured corpus luteum cyst, appendicitis, ovarian torsion, perforated viscus, abruption, septic abortion.
• Complications: haemorrhagic shock, disseminated intravascular coagulation, death, loss of tube, anaemia.

Diagnosis is clinical, and tests must not delay surgery in an unstable patient.

• Urine pregnancy test at the bedside.
• Bedside ultrasound: free fluid in the pelvis and in Morison's pouch.
• Haemoglobin, cross-match 4 units, blood group and Rhesus status.
• Serum hCG only if the patient is stable.
• Culdocentesis or abdominal paracentesis showing non-clotting blood if ultrasound is unavailable.

The principle is immediate resuscitation and emergency surgery to control bleeding.

• Supportive: call for senior surgeon and anaesthetist; two large-bore cannulae; Ringer's lactate 1 litre rapidly, repeat as needed; transfuse blood early, O negative if cross-match is not ready; keep the patient warm; oxygen at 10 to 15 L/min; urinary catheter.
• Pharmacological: tranexamic acid 1 g IV over 10 minutes; ceftriaxone 1 g IV single dose at induction; analgesia with morphine 2.5 to 5 mg IV titrated; no methotrexate.
• Procedures: emergency laparotomy with salpingectomy and clamping of bleeding vessels; laparoscopic approach only if the patient is stable.
• Special groups: Rhesus negative women give anti-D immunoglobulin 250 IU IM within 72 hours; Jehovah's Witness patients use cell salvage if available and agreed.
• Red flags: persistent hypotension, falling haemoglobin, ongoing bleeding, coagulopathy.
• Follow-up: haemoglobin daily in hospital; iron: ferrous sulphate 200 mg oral 8-hourly for 3 months; review at 6 weeks; counsel on recurrence risk and early scan in the next pregnancy.