Ruptured ectopic pregnancy with a negative urinary pregnancy test after methotrexate treatment – challenges of diagnosis in the emergency department

We present a case of a 21-year-old woman, who attended our Emergency Department (ED) in shock. A reliable history was challenging due to her clinical state and poor grasp of English; however, she gave a 3-day history of constant lower abdominal pain similar but worse than her menses. An episode of loss of consciousness prompted an ED attendance. She appeared pale, diaphoretic, and was hypotensive with a normal heart rate. Her abdomen was generally tender with left lower quadrant guarding. Her haemoglobin was 89 g/L and lactate 1.3mmol/L. Two qualitative urinary human chorionic gonadotropin (bhCG) tests (Alere International, Ireland) were negative and her serum bhCG was 15 IU/L. A Point of Care Ultrasound scan was performed (Sparq, Philips Healthcare, Netherlands) showing hemoperitoneum characterised by free fluid superior to the spleen (Figure 1). Hemoperitoneum in the left upper quadrant accumulates first in the subphrenic space due to attachments of the phrenicocolic ligament and in large amounts, subsequently in the splenorenal recess. Based on the assessment thus far a diagnosis of ruptured ectopic pregnancy (EP) was considered. She was monitored in the resuscitation room where she remained hypotensive, and subsequently an emergency laparotomy through a lowtransverse incision identified a ruptured distal tubal EP. A right salpingectomy was performed with evacuation of 2 l of intraabdominal blood. Histopathology confirmed intraluminal ectopic gestation. A latter collateral history suggested she was diagnosed with a pregnancy of unknown location 4weeks earlier abroad and had management with single dose methotrexate (MTX). No further details were available.