Learn about a USMLE Step 2 question involving a 28-year-old woman with a ruptured ectopic pregnancy, presenting with severe pelvic pain, hypotension, and a positive hCG. Understand the significance of emergent laparoscopy to control bleeding and remove damaged tissue.
A 28-year-old woman comes to the emergency department for evaluation of right-sided pelvic pain for the last week and light vaginal spotting. Today, the pain became severe, and the patient subsequently developed lightheadedness. The patient has not had a fever or vomiting. She had pelvic inflammatory disease two years ago and is currently sexually active with one biologically male partner. Her periods are irregular, and she reports that her last normal menstrual cycle was three months ago. Temperature is 37.0°C (98.6°F), pulse is 132/min, respiratory rate is 22/min, blood pressure is 88/62 mmHg, and oxygen saturation is 98% on room air. On examination, the patient appears pale and in pain. There is diffuse abdominal tenderness with rebound tenderness and guarding. Serum hCG is 3,900 IU/L. Ultrasound shows evidence of an adnexal mass and free fluid in the pelvis. There is no intrauterine pregnancy visualized. Which of the following is the best next step in management?
A. Laparoscopy
B. Methotrexate
C. Local feticidal injection
D. Salpingostomy
E. Hysterectomy
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
A. Laparoscopy
Before we get to the Main Explanation, let’s see why the answer wasn’t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today’s incorrect answers are…
B. Methotrexate
Incorrect: Methotrexate can be used in a small subset of patients with ectopic pregnancy who meet the following criteria: hemodynamic stability, no suspicion of impending or active tubal rupture, low and declining serum hCG levels, no fetal cardiac activity, capability of close follow up, and no contraindications to methotrexate therapy. This patient is hemodynamically unstable with signs of a tubal rupture and is therefore not a candidate for methotrexate therapy.
C. Local feticidal injection
Incorrect: Feticidal injection is occasionally used to manage an unruptured ectopic pregnancy when there is a concurrent intrauterine pregnancy which is being preserved. This patient is unstable with a likely ruptured ectopic pregnancy requiring emergent surgery.
D. Salpingostomy
Incorrect: Salpingostomy involves incising the fallopian tube and removing the tubal pregnancy while leaving the remaining tube intact. Salpingostomy is an option for patients with an unruptured ectopic pregnancy. This patient has evidence of tubal rupture.
E. Hysterectomy
Incorrect: A hysterectomy is not routinely indicated for patients with a ruptured ectopic pregnancy.
Main Explanation

This patient presents with severe pelvic pain, hypotension, and a positive hCG without the presence of an intrauterine pregnancy on ultrasound. These findings, along with free fluid in the pelvis, suggest a ruptured ectopic pregnancy. Emergent laparoscopy is indicated to control the bleeding and remove the damaged tissue. The patient’s preceding symptoms of unilateral pelvic pain and vaginal bleeding were likely symptoms of the ectopic pregnancy prior to rupture. Previous pelvic inflammatory disease is a risk factor for ectopic pregnancy.
The first step in assessing patients with acute pelvic pain is to establish stability. Findings of hypotension and tachycardia are concerning for internal bleeding from an etiology such as a ruptured ectopic pregnancy. Ectopic pregnancy represents one of the true gynecologic emergencies that can cause acute pelvic pain in a biological female. It occurs when an embryo implants outside of the uterine cavity, usually in the fallopian tube. As the fetus grows, the fallopian tube is unable to accommodate the growing fetus, leading to rupture. Patients typically present with significant abdominal and pelvic pain, syncope or lightheadedness, with or without recent vaginal bleeding. In the presence of rupture, the abdominal exam typically shows rebound tenderness and guarding. Emergent surgery is the only option for management after rupture occurs; however, less invasive treatment with methotrexate may be considered if the ectopic pregnancy is found prior to rupture in select circumstances.

Major takeaway
Acute management of a patient with a ruptured ectopic pregnancy consists of stabilizing the patient and emergent laparoscopy.
References
Mullany K, Minneci M, Monjazeb R, C Coiado O. Overview of ectopic pregnancy diagnosis, management, and innovation. Womens Health (Lond). 2023 Jan-Dec;19:17455057231160349. doi: 10.1177/17455057231160349. PMID: 36999281; PMCID: PMC10071153. ––––––––––––
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