Abstract
Ectopic pregnancy remains a life-threatening emergency in women of reproductive age. However, atypical presentations can obscure diagnosis and delay life-saving interventions. This case highlights a 40-year-old woman who presented with acute urinary retention and abdominal distension, initially misinterpreted as a cervical neoplastic lesion on CT imaging. Subsequent evaluation in the Emergency Department revealed a ruptured ectopic pregnancy with hemoperitoneum. This case underscores the critical importance of structured emergency assessment and a high index of suspicion for ectopic pregnancy in atypical presentations.
Case Presentation
Primary Survey
A 40-year-old female, P2L3A1, presented to the Emergency Department with diffuse, non-radiating abdominal pain and abdominal distension for one and a half days, associated with nausea and inability to pass urine, stools, or flatus during the same period.
Airway (A): Patient alert, talking coherently, airway patent.
Breathing (B): Bilateral air entry equal, no added sounds, SpO₂ 99% on room air, respiratory rate 20/min.
Circulation (C): Pulse 110 bpm, BP 110/70 mmHg, pallor present, S1S2 heard, no murmurs.
Disability (D): GCS 15/15, moves all four limbs, capillary blood glucose 136 mg/dL.
Exposure (E): Afebrile (98.6°F), no external injuries, mild abdominal distension noted.
Secondary Survey
History revealed that the patient had been evaluated at an outside hospital one day prior, where she was treated with Inj. Tramadol 100 mg IV and Inj. Pantoprazole 40 mg IV. Bladder catheterization drained approximately 1000 mL of urine. CT abdomen performed outside showed mild to moderate peritoneal fluid and a soft tissue dense lesion measuring 44 × 40 mm involving the anterior and posterior lip of the cervix, reported as ?neoplastic lesion.
Menstrual history: Regular cycles (3/30 days), 3–4 pads per day, LMP 15/5/25 (Day 5 of cycle). History of medical termination of pregnancy (MTP) with pills on 26/6/25 (records unavailable).
Physical Examination
Abdomen: Soft, distended, umbilicus everted, diffuse tenderness more over both iliac fossae and suprapubic region. Bowel sounds present.
Investigations
Arterial Blood Gas (ABG): pH 7.44, Na⁺ 132 mmol/L, K⁺ 4.5 mmol/L, Cl⁻ 104 mmol/L, Glucose 136 mg/dL, Lactate 2.0 mmol/L, Hb 7.1 g/dL, HCO₃⁻ 24.3 mmol/L.
E-FAST: Free fluid noted in the abdomen, distended bladder (approximately 700 mL of urine).
Urine Pregnancy Test (UPT): Positive.
Emergency Ultrasound Abdomen and Pelvis: Free fluid seen in the abdomen and pelvis with diffuse echogenic contents suggesting clots and hemoperitoneum. Uterus normal in size with endometrial thickness 4.5 mm. No intrauterine gestational sac visualized. Both ovaries obscured; doubtful hypoechoic lesion with peripheral vascularity seen in the right adnexal region—suggestive of ruptured right ectopic pregnancy with hemoperitoneum.
Management and Outcome
The patient was catheterized and resuscitated in the Emergency Department. With a positive UPT, low hemoglobin, and ultrasound evidence of hemoperitoneum and adnexal lesion, an urgent Obstetrics and Gynecology (OG) consultation was obtained. The patient was shifted to the operating theatre for surgical management. Diagnostic laparoscopy revealed a ruptured right tubal ectopic pregnancy with approximately 1.2 L of hemoperitoneum. A laparoscopic bilateral salpingectomy was performed, and the patient was stabilized postoperatively.
Discussion
Ectopic pregnancy accounts for approximately 1–2% of all pregnancies and remains a significant cause of maternal morbidity and mortality in the first trimester. This case illustrates an uncommon presentation of ruptured ectopic pregnancy, initially masquerading as acute urinary retention with misleading CT findings suggestive of a cervical neoplasm.
The classic triad of ectopic pregnancy includes: (1) Amenorrhea, (2) Abdominal pain, and (3) Vaginal bleeding. However, this triad is observed in fewer than 50% of cases. Atypical symptoms such as gastrointestinal discomfort or urinary retention can further complicate diagnosis. In this case, early CT interpretation led to diagnostic confusion, emphasizing the pivotal role of bedside urine pregnancy testing and point-of-care ultrasound in the Emergency Department.
This case underscores the importance of maintaining a high index of suspicion for ectopic pregnancy in all reproductive-age females presenting with acute abdomen, even when alternate diagnoses appear more likely. Prompt recognition and surgical intervention are essential to prevent catastrophic outcomes.
Conclusion
This case highlights an unusual presentation of ruptured ectopic pregnancy masquerading as acute urinary retention, which could have led to a potentially fatal outcome if misdiagnosed. A structured primary and secondary survey, along with bedside investigations such as UPT and focused ultrasound, are invaluable in the timely identification and management of such emergencies.
References
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- ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018;131(3):e91–e103.
- Shaw JL, Dey SK, Critchley HO, Horne AW. Current knowledge of the aetiology of human tubal ectopic pregnancy. Hum Reprod Update. 2010;16(4):432–444.
- Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250–261.
- Farquhar CM. Ectopic pregnancy. Lancet. 2005;366(9485):583–591.
Dr. Avinash S
Department of Emergency Medicine,
Kauvery Hospital, Alwarpet, Chennai.[1]
Dr . Ashok Nandagopal
HOD, Department of Emergency Medicine,
Kauvery Hospital, Alwarpet, Chennai.[1]