Question

A twenty year old woman has been brought to casualty with blood pressure 70/40 mm Hg, pulse rate 120/minute, and a positive urine pregnancy test. She should be managed by

• A. Immediate laparotomy
• B. Laparoscopy
• C. Culdocentesis
• D. Resuscitation and medical management

Hint:

Shock plus a positive pregnancy test means a likely ruptured ectopic pregnancy: the bleeding must be controlled surgically without delay.

Answer 1

The Correct Option is A

Step 1: Understanding the Question:
A young woman with a positive pregnancy test arrives in shock, blood pressure 70/40 mm Hg and pulse 120/minute. We need the correct immediate management step.

Step 2: Key Concept:
A positive pregnancy test with signs of hypovolemic shock is a ruptured ectopic pregnancy until proven otherwise. Heavy internal bleeding from a ruptured tubal pregnancy causes exactly this picture of low blood pressure and a fast, thready pulse, and it is a surgical emergency.

Step 3: Detailed Explanation:
Immediate laparotomy allows rapid entry into the abdomen, control of bleeding by clamping or removing the ruptured tube, and evacuation of blood, all within minutes, which is exactly what a patient in hemorrhagic shock needs. Fluid resuscitation and blood transfusion are started at the same time, but they run alongside surgery, they do not replace it, because the bleeding source must be controlled to stop the shock from worsening. This makes option (1) correct.
Laparoscopy takes longer to set up, needs general anesthesia and creation of a pneumoperitoneum, both of which are poorly tolerated in a hemodynamically unstable patient, and it is reserved for stable patients with suspected ectopic pregnancy. This rules out option (2).
Culdocentesis, needle aspiration of blood from the pouch of Douglas, is an older diagnostic test to confirm hemoperitoneum. It wastes precious time in a patient who is already in shock with an obvious clinical diagnosis, and it does nothing to stop the bleeding. This rules out option (3).
Resuscitation and medical management alone will not stop ongoing internal bleeding from a ruptured ectopic pregnancy, and delaying surgery in favour of medical treatment alone would let the patient continue to bleed and deteriorate. This rules out option (4).

Step 4: Final Answer:
A hemodynamically unstable patient with a positive pregnancy test needs urgent surgical control of bleeding, done together with resuscitation, not instead of it.
Hence, the correct answer is option (1), immediate laparotomy.