Ans. is b i.e. Ruptured ectopic pregnancy The picture given in the question classically represents a case of ruptured ectopics pregnancy. Symptom In Ectopic pregnancy triad of : Amenorrhea (seen in 75% cases) followed by : Abdominal pain (seen in 100% cases, it is the most consistent symptom of ectopic pregnancy). Appearance of vaginal bleeding are seen : The above triad may be accompanied by nausea, vomiting, fainting attacks or syncope. Patient may present in shock with pallor, tachycardia, hypotension and cold clammy extremities. Examination General examination : -- P/R T -- Pallor +nt -- BP .1, -- Slight intermittent pyrexia due to absorption of products of degeneration. Per Abdomen - Abdomen is tense, tender and distended. -- Shifting dullness may be present (depending on the amount of hemorrhage). -- Rigidity / muscle guarding +/--, -- Cullen's sign - bluish discolouration around the umbilicus may be present. On Bimanual examination -- Vaginal mucosa appears blanched.deg -- Uterus : normal size / slightly bulky. -- Extreme tenderness on cervical movement -- Fornices - tender. (Remember - tenderness in pelvis is the most constant sign of Ectopic pregnancy). -- U/L adnexal mass : is palpable in one third to half of patient. Culdocesitt:si It is a simple technique used to identify hemoperitoneum. Fluid is aspirated from cul-de-sac posterior fornix with the help of a needle. If non clotting blood is obtained, it is indicative of an intraperitoneal bleed and probably a ruptured ectopic. Note : If the aspirated blood clots, it may have been obtained from an adjacent blood vessel rather than from bleeding ectopic pregnancy. The women in the question is presenting with amenorrhea of 6 weeks and pain in abdomen. On USG - fluid is seen in POD and aspiration of dark coloured blood which fails to clot - all these features leave no doubt of ectopic pregnancy. "Sonographic absence of uterine pregnancy, a positive pregnancy test ($ -HCG), fluid in cul-de-sac and an abnormal pelvic mass. ectopic pregnancy is almost ceain."