Ectopic Pregnancy Summary

Definition & Incidence

  • Pregnancy outside uterine cavity
  • Incidence: 11 in 1000 pregnancies
  • 93-98% in fallopian tubes
  • Ampulla (73-75%), Isthmus (13%), Fimbria (12%)

Red Flag Symptoms

  • Abdominal/pelvic pain + amenorrhea
  • Vaginal bleeding
  • Shoulder tip pain
  • Dizziness/syncope
  • Signs of shock

Key Risk Factors

  • Previous ectopic pregnancy
  • PID history
  • Pelvic/tubal surgery
  • Infertility/ART
  • Smoking
  • Age >35 years

ED Management

  • Urine pregnancy test for all
  • Resuscitate if unstable
  • Immediate gynae referral if:
  • - Pain + abdominal tenderness
  • - Pelvic tenderness
  • - Cervical motion tenderness

Treatment Criteria

  • Methotrexate: hCG <1500, mass <35mm, stable
  • Surgery: hCG ≥5000, pain, mass ≥35mm, unstable
  • Choice: hCG 1500-5000, stable

Complications

  • Tubal rupture (after 6 weeks)
  • Intra-abdominal bleeding
  • Recurrence (18.5%)
  • Psychological impact

Investigations

  • Transvaginal ultrasound (gold standard)
  • Serial hCG monitoring
  • Laparoscopy if diagnosis uncertain

Ectopic Pregnancy

Pregnancy outside the uterine cavity - a gynecological emergency requiring prompt recognition and management

Overview

An ectopic pregnancy is a pregnancy outside the uterine cavity, with an ectopic pregnancy occurring in about 11 in 1000 pregnancies. Most ectopic pregnancies (93–98%) occur in the fallopian tube and may implant in the ampulla (73–75%), isthmus (about 13%), or fimbria (about 12%). The others are non-tubal and may implant in the ovary, abdomen, cervix, caesarean section scar, or the interstitial part of the fallopian tube.

Emergency: Ectopic pregnancy is a life-threatening condition. Rupture can cause massive intra-abdominal bleeding and maternal death.

Risk Factors

Ectopic pregnancy is often associated with risk factors that lead to tubal epithelial damage. About a third of women with an ectopic pregnancy will have no known risk factors.

Major Risk Factors

  • Previous ectopic pregnancy
  • History of pelvic inflammatory disease
  • History of tubal or other pelvic surgery
  • History of sterilisation or reversal of sterilisation

Other Risk Factors

  • History of infertility
  • Assisted reproductive techniques
  • Cigarette smoking
  • Maternal age over 35 years
  • Having multiple sexual partners

Complications

Tubal Rupture

  • If undiagnosed and untreated, spontaneous tubal abortion occurs in about 50% of cases
  • If persistent, the tube may rupture causing intra-abdominal bleeding
  • Can lead to haemodynamic instability and maternal death
  • Rupture usually occurs after 6 weeks
  • Timing depends on implantation site

Other Complications

  • Recurrent ectopic pregnancy (about 18.5% recurrence rate)
  • Psychological effects
    • Grief, anxiety, and depression
    • Common after pregnancy loss
  • Future fertility issues

Clinical Features

Symptoms

Common Symptoms

  • Abdominal or pelvic pain
  • Amenorrhoea or missed period
  • Vaginal bleeding

Less Common Symptoms

  • Breast tenderness
  • Gastrointestinal symptoms (diarrhoea/vomiting)
  • Dizziness, fainting or syncope
  • Shoulder tip pain (due to diaphragmatic irritation)
  • Urinary symptoms
  • Passage of tissue
  • Rectal pressure or pain on defaecation

Signs

More Common Signs

  • Pelvic tenderness
  • Adnexal tenderness
  • Abdominal tenderness

Signs of Rupture/Instability

  • Cervical motion tenderness
  • Rebound tenderness or peritoneal signs
  • Pallor
  • Abdominal distension
  • Enlarged uterus
  • Tachycardia or hypotension
  • Shock or collapse
  • Orthostatic hypotension

Clinical Awareness: During clinical assessment of women of reproductive age, be aware that they may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific. The symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions – for example, gastrointestinal conditions or urinary tract infection.

Differential Diagnosis

Bleeding in Early Pregnancy

  • Miscarriage
  • Molar pregnancy
  • Urethral bleeding
  • Haemorrhoids
  • Trauma of cervix, vagina or vulva
  • Cancer of cervix, vagina or vulva
  • Vaginitis
  • Cervicitis, cervical ectropion, or cervical polyps

Pain in Early Pregnancy

  • Miscarriage
  • Ruptured ovarian corpus luteal cyst
  • Pregnancy-related degeneration of a fibroid
  • Musculoskeletal pain
  • Urinary tract infection
  • Constipation
  • Irritable bowel syndrome
  • Pelvic inflammatory disease
  • Appendicitis
  • Renal colic
  • Bowel obstruction
  • Adhesions
  • Ovarian cyst (torsion, rupture, or bleeding)
  • Torsion of a fibroid
  • Pelvic vein thrombosis

Emergency Department Management

Initial Assessment Protocol
  1. Urine pregnancy test for all women of reproductive age with abdominal pain or bleeding
  2. Resuscitate immediately if signs of haemodynamic instability (pallor, tachycardia, hypotension, shock, collapse) or significant bleeding/pain
  3. Immediate referral to early pregnancy assessment service/gynaecology if:
    • Positive pregnancy test AND
    • Pain and abdominal tenderness OR
    • Pelvic tenderness OR
    • Cervical motion tenderness

Expectant Management

Use expectant management for women with a pregnancy of less than 6 weeks' gestation who are bleeding but not in pain, and who have no risk factors, such as a previous ectopic pregnancy.

Advise these women:

  • To return if bleeding continues or pain develops
  • To repeat a urine pregnancy test after 7–10 days and to return if it is positive
  • A negative pregnancy test means that the pregnancy has miscarried

Specialist Management

Diagnostic Approach

Transvaginal ultrasound is the diagnostic tool of choice for a suspected ectopic pregnancy. It is used to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. Repeat transvaginal scans, serial hCG levels, and laparoscopy may be used to distinguish between a normal intrauterine pregnancy, an ectopic pregnancy, a miscarriage, and a molar pregnancy.

Treatment Options

Expectant Management

  • Option for women with minimal/no symptoms
  • Clinically stable patients
  • Active intervention if symptoms occur or hCG fails to decrease

Medical Management (Methotrexate)

  • First-line for women who can follow up
  • Criteria:
    • No significant pain
    • Unruptured ectopic pregnancy
    • Adnexal mass <35 mm with no visible heartbeat
    • Serum hCG <1500 IU/L
    • No intrauterine pregnancy confirmed on ultrasound

Surgical Management

  • First-line if unable to follow up or any of:
  • Significant pain
  • Adnexal mass ≥35 mm
  • Fetal heartbeat visible on ultrasound
  • Serum hCG ≥5000 IU/L
  • Haemodynamic instability
  • Options: Salpingectomy or salpingotomy (laparoscopic or open)

Choice of Treatment

  • Offered when hCG 1500-5000 IU/L
  • Patient able to return for follow-up
  • No significant pain
  • Unruptured ectopic with mass <35 mm, no heartbeat
  • No intrauterine pregnancy confirmed
  • Choice between methotrexate or surgery

Follow-up and Additional Care

  • All women (except salpingectomy) require follow-up until hCG reaches non-pregnant levels (may take up to 6 weeks)
  • Anti-D immunoglobulin for all rhesus-negative women after surgical removal
  • Psychological support and counseling
  • Contraception advice
  • Future pregnancy planning discussion