Ruptured ectopic pregnancy with a negative urine pregnancy test

Ectopic pregnancy is commonly seen as a differential diagnosis of first-trimester vaginal bleeding. Often the diagnosis is made based on a combination of exam findings, transvaginal ultrasound, and a positive pregnancy test. Our case describes a patient with a history of ectopic pregnancy treated with methotrexate and serial human chorionic gonadotropin measurements that were decreasing appropriately. At the time of evaluation, her urine pregnancy test was negative; however, she was confirmed to have a ruptured tubal ectopic pregnancy. This case highlights the variable presentation of ectopic pregnancies and the importance of combining exam findings with ultrasound and laboratory results.