MUST be excluded before diagnosing any other cause of pain or bleeding, particularly in the first trimester of pregnancy - always refer to hospital. Typically presents at 7–8 weeks gestation with extreme pain. May be asymptomatic or found incidentally on an early pregnancy scan. The pregnancy test is almost always positive. However, a negative pregnancy test in a woman with clinical features of ectopic pregnancy does not absolutely exclude an ectopic pregnancy; but does make the diagnosis highly unlikely.
The main risk factor for ectopic pregnancy is damage to the fallopian tubes. Other common risk factors are:
- History of ectopic pregnancy
- History of tubal surgery
- IUS in situ when implanting
- Failed emergency contraception
- NB - Many women may appear not to have missed a menstrual period, as vaginal bleeding may occur at the time of the expected period
- Lower abdominal/pelvic pain
- Vary from mild to severe
- Often unilateral.
- Abnormal vaginal bleeding
- Colour change
- Flow volume (rare)
- Unilateral abdominal tenderness
- Cervical excitation
- +/- adnexal mass
- Signs of haemodynamic compromise:
- Signs of peritoneal irritation:
- Abdominal guarding
- Rebound tenderness
- Rigid abdomen
- Pregnancy test (beta hCG - urine and blood)
- NB in a viable intrauterine pregnancy, hCG concentration in the blood doubles every 48 hours
- In an ectopic pregnancy hCG levels rise slowly (<66% over 48hours)
- USS of abdomen to look for the ectopic - note that there may be a pseudosac present within the uterine cavity and the actual ectopic may be elsewhere
NB: the risk of having another ectopic pregnancy in the future is increased to around 10%.
If the woman has minimal pain, serum hCG is decreasing and the ectopic is not visible on USS then the ectopic fails spontaneously and resolves without any active intervention. Also known as expectant management.
Only an option if the woman has minimal pain, a small un-ruptured adnexal mass <4cm is visible on USS and hCG concentration is <1500IU/l.
Methotrexate is given as a single IM injection (dose based on body surface area). 15% of women require a second dose.
Women are followed up until their hCG is <25IU/l.
Women should avoid a further pregnancy in the next 3 months (due to teratogenicity of methotrexate).
Option in women who are haemodynamically unstable following resuscitation.
Laparoscopic salpingectomy if contralateral tube appears normal. But if other tube is damaged and woman wishes to be pregnant in future then a laparoscopic salpingostomy is performed.