Ectopic pregnancy typically presents 6 to 8 weeks after the last normal menstrual period, but can present earlier or later.
Risk of ectopic pregnancy increases with prior ectopic pregnancy, tubal surgery, history of sexually transmitted infections, smoking, in vitro fertilization, or if the woman is pregnant despite IUD usage.
Classic symptoms and signs of ectopic pregnancy are pain, vaginal bleeding, and amenorrhea. Hemodynamic instability and cervical motion tenderness may indicate rupture or imminent rupture of an ectopic pregnancy.
If the woman is hemodynamically stable, transvaginal ultrasound is the initial test of choice.
Treatment approaches for ectopic pregnancy include expectant, medical (methotrexate), or surgical (salpingectomy or salpingostomy).
If an ectopic pregnancy ruptures, the woman may present in shock from blood loss and with unusual patterns of referred pain from intraperitoneal blood.
An ectopic pregnancy occurs when a fertilized ovum implants and matures outside the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal hemorrhage.
History and exam
Key diagnostic factors
- abdominal pain
- vaginal bleeding
- abdominal tenderness
- adnexal tenderness or mass
- blood in vaginal vault
- hemodynamic instability, orthostatic hypotension
- cervical motion tenderness
Other diagnostic factors
- urge to defecate
- referred shoulder pain
- previous ectopic pregnancy
- previous tubal sterilization surgery
- in utero diethylstilbestrol exposure of the mother
- intrauterine device (IUD) use
- previous genital infections
- chronic salpingitis
- salpingitis isthmica nodosa
- multiple sexual partners
- assisted reproductive technology (ART)
- first sexual encounter <18 years
- maternal age >35 years
- tubal reconstruction surgery
1st investigations to order
- urine or serum pregnancy test
- high-resolution transvaginal ultrasound (TVUS)
- transabdominal ultrasound
Investigations to consider
- serial serum human chorionic gonadotropin (hCG)
- uterine aspiration
tubal ectopic pregnancy: ruptured ectopic pregnancy or failed medical management
tubal ectopic pregnancy: moderate risk or failed expectant management
tubal ectopic pregnancy: low risk
- Acute appendicitis
- Ovarian torsion
- Management of pregnancy of unknown location and tubal and nontubal ectopic pregnancies
- Ectopic pregnancy and miscarriage: diagnosis and initial management
Ectopic pregnancy: what is it?
Ectopic pregnancy: what treatments work?More Patient leaflets
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