Medical history Twenty-six-year-old primiparous patient, demand urgent attention complaining of severe abdominal pain and brown vaginal discharge, without foul odor, about 2 hours. Reports 2 urine tests positive for pregnancy and a supposed 5 weeks and 5 days gestational age (by date of last menstruation). On physical examination, she presents algic facies, afebrile, full pulse, abdomen diffusely painful to palpation and positive Blumberg sign in the right iliac fossa. To gynaecological examination, the cervix is long, enclosed and retroverted, regular sized uterus and absence of active bleeding. The endovaginal Ultrasound was performed, see attached image. Transvaginal ultrasound showing adnexal region uterine on the rightTransvaginal ultrasound showing uterus and fornix, in longitudinal section. Question:What is the most likely diagnosis and indicated medical management? Ectopic pregnancy. Confirm pregnancy by β-hCG and perform drug therapy with methotrexate, once the gestation is very early and the patient is hemodynamically stable. Acute appendicitis. Correcting disorders of blood volume indicate perioperative antibiotic prophylaxis and carry on an emergency appendectomy. Ectopic pregnancy. Confirm pregnancy by β-hCG, correcting disorders of blood volume and realize a radical surgical treatment (salpingectomy), because the patient has a high probability of tubal rupture. Inevitable miscarriage. Correcting disorders of blood volume and, if there is no spontaneous resolution, proceed to uterine emptying. Time is Up! Time's up
