Code Status case · Advanced · Premium
Pelvic pain in a 31-year-old woman
“I started having pain low on the right this morning. I noticed some spotting yesterday.”
“Right-sided pelvic pain since this morning with light spotting since yesterday. Home pregnancy test was positive three days ago. No ultrasound yet.”
Your challenge
Isabel and her partner have been trying for a while, and three days ago a home test finally came back positive. Now she has pain low on the right and some spotting, and no one has done an ultrasound yet. A miscarriage, a pregnancy in the wrong place, a bleeding cyst, a twisted ovary or appendicitis can all start like this. She looks stable, and that can be misleading: the plan has to keep up with a patient who may not stay that way.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Ruptured Ectopic Pregnancy
Lesson 1
Pain or Bleeding in Pregnancy May Be Ectopic
A stable patient can still have a dangerous ectopic pregnancy.
- Pelvic pain or syncope in pregnancy may be ectopic
- Test for pregnancy early when pregnancy is possible
- Ectopic can occur with normal vitals and no risks
- Low hCG does not exclude rupture
Lesson 2
Ultrasound Locates Pregnancy and Bleeding
An empty uterus alone does not prove an ectopic pregnancy.
- Yolk sac or embryo in the uterus confirms location
- Yolk sac outside the uterus confirms ectopic
- Increasing free fluid may mean bleeding
- Positive test, no pregnancy seen: location unknown
Lesson 3
One hCG Level Cannot Locate a Pregnancy
Use symptoms, ultrasound, and hCG trends together.
- Empty uterus above hCG cutoff does not prove ectopic
- If location is unknown, repeat hCG in 48 hours
- Repeat ultrasound based on hCG trends and symptoms
- Worsening pain or poor follow-up bars discharge
Lesson 4
Ruptured Ectopic Pregnancy Needs Surgery
Methotrexate is an option only for selected stable, unruptured ectopic pregnancies.
- Rupture or instability needs urgent surgery
- Exclude rupture and confirm methotrexate eligibility
- Reliable follow-up is part of methotrexate eligibility
- Suspected rupture needs blood and gynecology now
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Isabel is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.