Picture showing a Tubal Pregnancy with a human embryo in 7th week pregnancy
Courtesy of Ed Uthman, MD (released into public domain)
We often think that in cases of intra-abdominal hemorrhage, tachycardia is most often the first physical manifestation. We recently saw a case of ruptured ectopic pregnancy that presented with bradycardia. Actually, a number of literature has shown that bradycardia is a well-established phenomenon noted in cases of hemoperitoneum, including ruptured ectopic pregnancy.
Similarly, in cases of traumatic hemorrhage, about a third of these patients can present with bradycardia even in the face of acute reduction in blood volume.
Although the exact mechanism for this phenomenon is not known, the hypothesized pathophysiology behind this relative or paradoxic bradycardia is vagal stimulation, either from the mechanoreceptors in the left ventricle or triggered by blood in the peritoneum.
The emergency physician should also be aware that because of the possibility of heterotopic pregnancy, the presence of an intrauterine pregnancy cannot still exclude the possibility of a concurrent ectopic pregnancy especially if the clinical signs are suggestive.
Also, a pelvic ultrasonographic examination demonstrating an empty uterus is sufficient to diagnose ectopic pregnancy if the quantitative Beta-hCG level is high enough.
Click here to download a short case report article illustrating this phenomenon.
1. Somers MP, Spears M, Maynard AS, Syverud SA. Ruptured heterotopic pregnancy presenting with relative bradycardia in a woman not receiving reproductive assistance. Ann Emerg Med. 2004 Mar;43(3):382-5.
2. Thomas I, Dixon J. Bradycardia in acute haemorrhage. BMJ. 2004 Feb 21;328(7437):451-3. Click here to access free.