<prompt> Basanti, a 28 yrs aged female with a history of 6 weeks of amenorrhoea presents with pain in abdomen; USG shows fluid In pouch of douglas. Aspiration yields dark color blood that fails to clot. Most probable diagnosis is :Ruptured ovarian cystRuptured ectopic pregnancyRed degeneration of fibroidPelvic abscess  <response>: 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 : -- PR 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 --, -- Cullens 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. -- UL 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. 