A woman at 8 weeks of gestation presents with sudden Flank pain, cold clammy skin, hypotension, and pain referred to as shoulder. What is the most likely diagnosis?

1. A

   Ruptured ectopic pregnancy

2. B

   Threatened abortion

3. C

   Molar pregnancy

4. D

   Acute appendicitis

Appeared in: NORCET 10 Prelims-2026

Explanation

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• The patient's symptoms constitute the classic presentation of a ruptured ectopic pregnancy, a major obstetric emergency.
• Hypotension and cold, clammy skin are cardinal signs of hypovolemic shock, caused by massive internal bleeding (hemoperitoneum) from the ruptured fallopian tube.
• The pain referred to the shoulder, known as Kehr's sign, is a specific symptom caused by blood accumulating under the diaphragm, irritating the phrenic nerve.
• The sudden onset of severe flank or abdominal pain is due to the tearing of the tubal tissue by the growing pregnancy.
• Rupture of an ectopic pregnancy most commonly occurs between 6 and 12 weeks of gestation, which aligns with the patient's history.

Why Other Options Were Wrong

• Option B: Threatened abortion typically involves vaginal bleeding and uterine cramping with a closed cervix. It does not cause profound hypovolemic shock or referred shoulder pain.
• Option C: Molar pregnancy usually presents with signs like a uterus larger than gestational age, severe nausea/vomiting, and dark brown 'prune juice' vaginal bleeding. Acute shock from rupture is not the typical presentation.
• Option D: Acute appendicitis causes pain that typically migrates to the right lower quadrant, along with fever, nausea, and vomiting. It does not explain the combination of profound shock and referred shoulder pain in a pregnant patient.

Related Visual

• Visual 1: Diagram - An illustration showing a ruptured ectopic pregnancy in the fallopian tube with blood accumulating in the peritoneal cavity and irritating the diaphragm, with an arrow pointing to the shoulder to explain Kehr's sign (referred pain).
• Visual 2: Ultrasound Image - A transvaginal ultrasound image depicting an adnexal mass separate from the ovary, consistent with an ectopic pregnancy, and free fluid (blood) in the cul-de-sac.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Diagnosis of acute obstetric emergencies, specifically ruptured ectopic pregnancy to guide bedside assessment, documentation, and the next nursing action.
• Recognizing the signs of a ruptured ectopic pregnancy is a critical nursing skill, as it is a leading cause of maternal mortality in the first trimester.
• Immediate nursing actions include establishing large-bore IV access for fluid and blood resuscitation, continuous hemodynamic monitoring, and preparing the patient for emergency surgery.
• This condition requires a rapid, coordinated response from the healthcare team to prevent maternal death from hemorrhage.

How to Approach the Question

• First, identify the patient's key characteristics: a woman at 8 weeks of gestation.
• Next, analyze the presenting signs and symptoms. Note the acuity ('sudden') and severity of the symptoms: flank pain, cold/clammy skin, hypotension, and shoulder pain.
• Synthesize the clinical picture. The combination of hypotension and cold/clammy skin points to hypovolemic shock. The referred shoulder pain (Kehr's sign) is a specific clue for diaphragmatic irritation by blood.
• Connect the findings to the patient's status. In a first-trimester pregnancy, the most common cause of massive intra-abdominal hemorrhage (hemoperitoneum) is a ruptured ectopic pregnancy.
• Evaluate each option against this clinical picture. Ruptured ectopic pregnancy perfectly matches all the signs and symptoms.
• Systematically rule out the other options by identifying why their typical presentations do not fit the patient's specific constellation of symptoms.

Concept Tested & Keywords

• Concept Tested: Diagnosis of acute obstetric emergencies, specifically ruptured ectopic pregnancy.
• Stem keywords: 8 weeks of gestation, sudden Flank pain, cold clammy skin, hypotension, pain referred to as shoulder
• Lead-in keywords: most likely diagnosis
• Clinical cues: The combination of hypotension and cold, clammy skin indicates hypovolemic shock.
• Clinical cues: Referred shoulder pain (Kehr's sign) is a classic indicator of diaphragmatic irritation from intra-abdominal blood (hemoperitoneum).

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