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Culdocentesis is a procedure used to diagnose the presence of ruptured ectopic pregnancy by evaluating for hemoperitoneum by inserting a needle and drawing back fluid from the pouch of Douglas. Ectopic pregnancy remains a large cause for early maternal morbidity and mortality, and culdocentesis is one of the tools that can be used for rapid diagnosis although it has largely been replaced by sonography, it is still regularly practiced in some countries. This activity outlines and reviews the role of the interprofessional team in evaluating, treating, and managing patients who undergo culdocentesis. Objectives: Identify the indications for culdocentesis. Describe the technique of culdocentesis. Recall potential complications of culdocentesis. Access free multiple choice questions on this topic.

At one point, culdocentesis was a mainstay for the evaluation and diagnosis of hemoperitoneum the increasing availability of high-resolution transvaginal sonography has largely replaced it.[1] Culdocentesis is still widely used in developing countries that may not have access to sonography, such as Papua New Guinea, where it is the most common aid for the diagnosis of ruptured ectopic pregnancy.[2]  This is especially important for diagnosis in countries with high rates of anemia and pelvic inflammatory disease, as these can mimic ruptured ectopic pregnancy.[3] Culdocentesis has been important in the diagnosis of ruptured ectopic pregnancy, especially in the days before sonography. Ruptured ectopic pregnancy is considered to be a surgical emergency, and prompt diagnosis is critical.[4] Culdocentesis can also aid in the diagnosis of other conditions. For example, acute salpingitis or pelvic inflammatory disease will have purulent peritoneal fluid. Endometrioma will have "chocolate" fluid and ascitic fluid return can be seen in other conditions.[3] Hemoperitoneum can be present in multiple pathologies and can cause false-positive results such as hemorrhagic ovarian cysts, torsion of an ovarian cyst, and ruptured ovarian follicles. A negative culdocentesis (clear or serosanguinous fluid return) does not exclude ectopic pregnancy, and repeat culdocentesis at a later time may be needed. A negative culdocentesis supports that there is likely no hemoperitoneum, and the fallopian tube is intact, but an ectopic pregnancy may still exist that has not yet ruptured. Almost 25% to 30% of ectopic pregnancies result in hemoperitoneum and is a significant cause of morbidity and mortality in reproductive-aged women.[2]

Complications include accidental puncture of visceral organs, the rectum, or the uterus. Puncture of blood vessels, cysts, or tumors. Aspiration of products of an ectopic pregnancy, peritoneal introduction of infected or malignant cancer-carrying cells.[1][5]

Rapid diagnosis of ruptured ectopic pregnancy is paramount to good patient outcomes. In high socioeconomic countries, ectopic pregnancy accounts for 1% to 2% of pregnancies, and it remains a leading cause of early maternal morbidity.[2] Multiple people from different professions must come together to diagnose, manage, and treat ruptured ectopic pregnancy. It often starts with nurses and emergency medical service providers who monitor the patient's vital signs and administer pain medications and fluids. Often these patients are hemodynamically unstable, and abnormal vital signs such as hypotension and tachycardia are the first indicators that there is a rupture. Next, the emergency physician evaluates the patient and often makes the diagnosis, but patient care does not stop there. Laboratory technicians must process labwork promptly, including the beta-human chorionic gonadotropin level and hemoglobin, and view fluid under microscopy. Blood blank personnel may need to be involved if the patient has hemorrhagic shock and requires blood products. Pharmacists are involved in dosing pain medications and/or tranexamic acid. Radiologists interpret ultrasound images (if ultrasound is available) to aid in diagnosis. Consulting physicians such as obstetric/gynecologic physicians or if obstetrics/gynecology is unavailable, general surgeons should be on standby for emergent surgery if a patient presents with a ruptured ectopic. Often these patients need to be monitored for several days, and the physicians, advanced practice providers, nurses, and nurses' aids on the inpatient floors monitor and observe these patients. It truly takes a team to orchestrate the care for these patients, and each individual has an important role to play in ensuring the best possible outcomes for these patients.