Critical Cases: Abdominal Cramping and Vaginal Bleeding


  • 25 y/o Female, G3P2012, presenting with vaginal bleeding.
  • Patient notes bleeding began last week and is longer than typical menses
  • Pt notes suprapubic abdominal cramping

Physical Temp:

  • 98.6 / BP 119/77 / Pulse 110 / RR 18 / SpO2 99%
  • Abdomen: Soft, mild surprapubic tenderness, no rebound, guarding, or rigidity
  • Pelvic: Clot noted in vaginal vault, no active bleeding. Mild uterine tenderness on bimanual

Differential Diagnosis

  • Menstruation, Dysfunctional Uterine Bleeding, Menorrhagia, Fibroids, Malignancy, Threatened Ab, Miscarriage, Ectopic Pregnancy

Initial Workup

  •  Upreg positive
  •  b-hCG quant pending
  • Type and screen




POCUS: No IUP. Complex L adnexal mass with some surrounding free fluid. 

b-hCG: 4924


  • Level 2 to OR with OB-gyn for ruptured ectopic pregnance (see image below)




Teaching points:

  • Urine pregnancy test for all women of childbearing age for abdominal pain or vaginal bleeding
  • Be suspicious of patient attributing vaginal bleeding to menses, this could still be an ectopic pregnancy!
  • Ultrasound findings of a complex adnexal mass must be attributed to ectopic pregnancy until proven otherwise, regardless of the serum beta-quant