Case Report Ruptured Ectopic Pregnancy with a Negative Urine Pregnancy Test Urgent message: Ectopic pregnancy must be considered in women of childbearing age who present with abdominal pain—even if ‘ruled out’ by a negative hCG test. Yi-An A. Lee, MD, MPH, Gino Farina, MD, and Helene Lhamon, MD Introduction The incidence of ectopic pregnancy is estimated to be 19.7 per 1,000 pregnancies and is responsible for 9% of pregnancy-related deaths. 1 Ectopic pregnancy is always near the top of the differential diagnosis for abdominal pain in women of childbearing age, but is generally con- sidered to be ruled out by a negative urine human chorionic gonadotropin (hCG) level. Standard urine hCG tests are able to detect ß hCG lev- els as low as 20 mIU/mL. This case report shows that an ectopic pregnancy can exist and be large enough to rup- ture at ß hCG levels below the threshold detectable by urine pregnancy screening tests. Considering the mor- tality and morbidity associated with a ruptured ectopic pregnancy, this case report emphasizes the necessity of confirming a negative serum quantitative hCG before ruling out ectopic pregnancy. [Note: While this case report concerns a patient who pre- sented in an ED setting, abdominal pain is a common pre- senting complaint in urgent care. The teaching points are highly relevant to the urgent care practitioner.] Case Report A 36-year-old female gravida 0 prima 0 whose last men- strual period was two months prior presented to the emergency department with the chief complaint of se- vere abdominal pain that awakened her from sleep. She described the pain as 10 out of 10 in severity (i.e., the worst pain imaginable in the patient’s estimation); the pain was greatest in the left lower quadrant, and be- came worse with any motion. The review of systems was pertinent for the pres- 26 ence of vaginal spotting and right shoulder pain, and for the absence of chest pain, shortness of breath, syn- cope, or fever. The patient’s past medical history was significant for infertility, fibroids, and irregular menses. She had no prior surgical history, took no medications, and had no allergies. She had no risk factors for ectopic pregnancy: no history of sexually transmitted diseases or pelvic in- flammatory disease, no prior gynecological surgery, no intrauterine device use, and she was not taking fertility medications. Her initial vitals were as follows: Ⅲ BP 90/52 Ⅲ Heart rate 103 Ⅲ Respiratory rate 24 Ⅲ Temperature 36.7 C (98.1°F) Ⅲ Pulse oximetry 100% on room air The patient was clearly uncomfortable, but not in acute distress. Cardiac exam revealed a regular rate and rhythm. Pulmonary exam was clear to ausculta- tion bilaterally. Abdominal exam revealed positive bowel sounds, soft without guarding but extremely tender to palpation, with diffuse rebound and a pos- itive pelvic shake. Pelvic exam was notable for cervi- cal motion tenderness and bilateral adnexal region tenderness; uterine and adnexal size were difficult to assess secondary to pain. The urine hCG was negative. Intravenous access was obtained, and a complete blood count, chemistry panel, blood type and cross, and serum quantitative hCG were sent to the laboratory. The patient was given intravenous fluids and the ob/gyn service was promptly consulted. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | N o v e m b e r 2 0 0 7 w w w. j u c m . c o m