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K
Spot Dx
24/F with acute lower abdominal pain, mild fever, and shock
Obstetrics & Gynecology
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Case Presentation
A 24-year-old female is rushed to a Health Center IV in Eastern Uganda with severe, acute-onset lower abdominal pain of 6 hours, which started in the right iliac fossa and is now generalized, radiating to her right shoulder. She collapsed once at home. She reports her last menstrual period was 3 weeks ago and was "normal," though she has experienced mild, foul-smelling vaginal discharge for two weeks, for which she self-medicated with oral amoxicillin. On examination, she is pale, cold, and clammy. Axillary temperature is 37.9°C, blood pressure is 82/50 mmHg, heart rate is 132 bpm (weak), and respiratory rate is 26 breaths/minute. Her abdomen is distended, rigid, with generalized tenderness and rebound guarding. Pelvic examination reveals cervical motion tenderness and a boggy fullness in the pouch of Douglas. A bedside urine pregnancy test is faintly positive.
Question
What is the most likely diagnosis, how do you reconcile the patient's 'normal' period 3 weeks ago and mild fever with this diagnosis, and what immediate, low-resource bedside procedure should you perform to confirm the presence of intraperitoneal blood?
Answer
The most likely diagnosis is a ruptured ectopic pregnancy. The 'normal period' 3 weeks ago was actually decidual bleeding (shedding of the endometrium due to fluctuating progesterone levels in ectopic pregnancy), and the mild fever (37.9°C) is a reactive pyrexia caused by peritoneal irritation from free blood (hemoperitoneum), which can mimic PID or appendicitis. To confirm hemoperitoneum in a resource-limited setting like a Health Center IV, perform a culdocentesis (or abdominal paracentesis) to aspirate non-clotting dark blood from the pouch of Douglas. Management must prioritize urgent laparotomy with controlled, judicious fluid resuscitation (permissive hypotension) using crystalloids to maintain a systolic BP of 80-90 mmHg, as aggressive fluid resuscitation will dislodge the protective clot and worsen internal hemorrhage before surgical control is achieved.
Clinical Pearl
Do not rule out ectopic pregnancy based on a 'recent normal period' or mild fever; decidual bleeding mimics menses, and hemoperitoneum causes chemical peritonitis with reactive pyrexia. Perform culdocentesis to confirm blood, and avoid aggressive fluid resuscitation (keep SBP 80-90 mmHg) to prevent dislodging the life-saving clot before laparotomy.