A 20-year-old gravida 0, para 0 woman was brought to the emergency department at 11:00 rM by ambulance. She complained of generalized abdominal pain and, in the opinion of the triage nurse, exhibited inappropriate behavior, removing her clothes and exposing herself in the waiting room. Vital signs were as follows: blood pressure, 110/65 mm Hg; pulse, 100 beats per minute; respirations, 26/min; and temperature, 37.2 C. The patient was triaged to a non-acute examining room.
She gave a history of having been treated three weeks earlier at another hospital for pelvic pain with a two-week course of medication that she did not complete because the pain had resolved after several days. A similar episode of pain recurred three days prior to her presentation at our emergency department. She was seen at another hospital, where she was treated with "two shots in the hips" and given a prescription that she did not fill. Subsequently the pain persisted and dizziness developed.
There was no nausea or vomiting, change in bowel movements, or urinary symptoms. Her last menstrual period was ten weeks prior to admission and she occasionally had unprotected sexual intercourse. She denied vaginal discharge or bleeding, prior pelvic surgery, or ectopic pregnancies, but she admitted to receiving antibiotic treatment for "pelvic infections" in the past.
On physical examination she was well developed, well nourished, and in obvious discomfort. She was afebrile, the supine pulse rate was 104 beats per minute, and the supine blood pressure was 110/60 mm Hg. The respiratory rate was 26/rain. On standing, her pulse rate rose to 120 and her systolic blood pressure fell to 90 mm Hg. Examination of the heart and lungs was normal. The abdominal examination revealed normal bowel sounds, slight distention, and diffuse tenderness with pelvic guarding andrebound. On pelvic examination, there was no blood or discharge and the cervix was markedly tender to palpation. Bimanual examination revealed diffuse uterine and adnexal tenderness and severe guarding that did not permit adnexal definition. Rectal examination revealed guaiac-negative stools and no masses or tenderness.
Urinalysis was unremarkable. Urine pregnancy test was positive. The complete blood count (CBC) revealed a hematocrit of 24% and a white blood cell count of 21,900/ram 3. A gynecological consultation was requested, but before culdocentesis could be performed the patient became hypotensive and tachycardic. An intravenous line was started with normal saline, wide open, and she was rushed to the operating room, where a left comual pregnancy with rupture and 2 L of intraperitoneal blood were noted on laparotomy.