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 signs of hypovolemic shock resulting from massive internal bleeding into the peritoneal cavity.
• Referred shoulder pain (Kehr's sign) is a specific indicator of diaphragmatic irritation caused by the pooling of blood (hemoperitoneum), which is a hallmark of a ruptured ectopic pregnancy.
• The sudden onset of severe flank or abdominal pain is caused by the physical tearing of the fallopian tube.
• This condition requires immediate surgical intervention to control the hemorrhage and prevent maternal mortality.

Why Other Options Were Wrong

• Option B: Threatened abortion typically presents with vaginal bleeding and mild to moderate uterine cramping, with a closed cervix. It does not cause the profound hypovolemic shock or hemoperitoneum that leads to referred shoulder pain.
• Option C: A molar pregnancy (hydatidiform mole) classically presents with signs like dark brown 'prune juice' vaginal bleeding, severe nausea and vomiting (hyperemesis gravidarum), and a uterine size larger than expected for gestational age. It does not typically present with the acute shock and shoulder pain described.
• Option D: Acute appendicitis causes right lower quadrant pain, fever, nausea, and vomiting. While it is an important differential for abdominal pain in pregnancy, it does not explain the profound hypovolemic shock or the referred shoulder pain, which is specific to diaphragmatic irritation.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Complications of Early Pregnancy to guide bedside assessment, documentation, and the next nursing action.
• Ruptured ectopic pregnancy is a leading cause of maternal mortality in the first trimester. Prompt recognition and intervention are critical.
• Nurses must be vigilant in assessing pregnant patients with abdominal pain for signs of hemodynamic instability (hypotension, tachycardia) and specific signs like shoulder pain, as these indicate a surgical emergency.
• What if? If the patient's blood pressure was stable and she only reported mild, intermittent pelvic pain and spotting, the immediate diagnosis would be less clear. The approach would shift from emergency surgery to a diagnostic workup including a transvaginal ultrasound and serial serum β-hCG levels to differentiate between a threatened abortion, a failing pregnancy, or an unruptured ectopic pregnancy.

How to Approach the Question

• First, identify the patient's core demographic: a woman in early pregnancy (8 weeks gestation).
• Next, cluster the presenting signs and symptoms into meaningful groups: 1) Signs of shock (cold clammy skin, hypotension), 2) Acute pain (sudden flank pain), and 3) A specific, localizing sign (pain referred to the shoulder).
• Recognize that this combination points towards a life-threatening condition involving massive internal bleeding.
• Specifically identify the 'shoulder pain' as Kehr's sign, which is a classic indicator of diaphragmatic irritation from blood in the abdomen (hemoperitoneum).
• Evaluate each option against this complete clinical picture. Ruptured ectopic pregnancy is the only diagnosis that accounts for the pregnancy, the severe internal hemorrhage causing shock, and the specific referred shoulder pain.
• Eliminate other options because they do not explain the full triad of symptoms. For example, threatened abortion doesn't cause shock, and appendicitis doesn't cause referred shoulder pain from hemoperitoneum.

Concept Tested & Keywords

• Concept Tested: Complications of Early Pregnancy
• Stem keywords: 8 weeks gestation, sudden flank pain, cold clammy skin, hypotension, pain referred to shoulder
• Lead-in keywords: most likely diagnosis
• Clinical cues: The combination of hypotension and referred shoulder pain is a critical cue for intra-abdominal hemorrhage.

Question ID

QgF19cVFYzsYtf1q5q_gt9

Copy ID

Reference Book

E6 Obstetrics Williams p. 18-33

E6 Medicine Harrison 22e Part 2 p. 1040-1042