• Clinical science

Ectopic pregnancy

Abstract

Ectopic pregnancy occurs when an embryo attaches outside of the uterus, most commonly in the fallopian tubes. It is frequently associated with pelvic inflammatory disease (PID), which may lead to stenosis of the fallopian tubes. This prevents the fertilized egg from passing through to the uterus, instead causing it to attach to the tube itself. In addition to signs of pregnancy, symptoms include abdominal pain and vaginal bleeding. The first diagnostic step is to confirm the pregnancy with a β-hCG test, which should be followed by a transvaginal ultrasound to determine the location of the pregnancy and the fetal heartbeat. Uncomplicated ectopic pregnancies often resolve spontaneously and are usually difficult to diagnose. Patients are typically hemodynamically stable with low, declining hCG concentrations (< 5000 IU/L). Complicated cases may involve tubal abortion or rupture, which can lead to intraabdominal bleeding and shock. Whereas uncomplicated cases are treated conservatively (e.g., methotrexate or expectant management), complicated ectopic pregnancy requires surgical removal. In cases of abdominal pain in women of reproductive age, it is therefore important to rule out ruptured ectopic pregnancy.

Etiology

Localization

  1. Fallopian tube (96% of cases): ampulla >> isthmus > fimbriae > interstitial pregnancy : e.g., cornual pregnancy
  2. Ovary (3% of cases)
  3. Abdomen (1% of cases)
  4. Cervix (very rare)

Risk factors

References:[1][2][3][4][5][6][7][8][9]

Clinical features

General symptoms of ectopic pregnancy

Patients usually present with signs and symptoms 4–6 weeks after their last menstrual period.

  • Lower abdominal pain and guarding
  • Vaginal bleeding
  • Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination
  • Tenderness in the area of the ectopic pregnancy
  • Cervical motion tenderness, closed cervix
  • Enlarged uterus
  • Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of myometrial distensibility.

Right lower quadrant pain may indicate appendicitis! Cervical motion tenderness may be a sign of PID!

Tubal rupture

References:[10][11][12]

Diagnostics

Every woman of reproductive age with abdominal pain should undergo a pregnancy test!

References:[13][14][15][16][17][18][19]

Differential diagnoses

Differential diagnoses of abnormal vaginal bleeding in women of reproductive age

Painful vaginal bleeding

Differential diagnosis Description of pain Findings
Ectopic pregnancy
  • Lower unilateral abdominal pain and guarding
Benign neoplasms
(e.g., adenomyosis, uterine leiomyoma)
Ovarian cyst rupture
  • Sudden onset of unilateral abdominal pain
  • Onset usually during physical activity (exercise, sexual intercourse)
Infection/Inflammation
(e.g, PID, cervicitis)

Endometriosis

  • Chronic pelvic pain that worsens before the onset of menses
Trauma
(e.g., foreign body, sexual abuse)
  • Bruising, hematoma, possible accompanying injuries

Painless vaginal bleeding

Differential diagnosis Findings

PCOS

Endometrial hyperplasia

  • Constant bleeding, intermenstrual bleeding
  • Ultrasonography shows endometrial thickening.

Endometrial polyp

Malignant neoplasms
(e.g., cervical cancer, endometrial cancer)
Iatrogenic
(e.g., anticoagulants, oral contraceptives, intrauterine devices)
  • Anticoagulants: easy bruising, bleeding tendency


References:[20][21][22][23][24][25][26][27][28]

The differential diagnoses listed here are not exhaustive.

Treatment

Management may be conservative or surgical, depending on the severity of the condition. Unstable patients require immediate hemodynamic support.

Conservative management

  • Indications
    • Uncomplicated ectopic pregnancies
    • Hemodynamic stability
    • β-hCG5000 mlU/mL
    • No renal, hepatic, or hematologic diseases
    • No fetal heartbeat and ectopic mass size < 4 cm
  • Treatment of choice: methotrexate (MTX)
    • Outcome comparable to surgery
    • A decrease in β-hCG levels should occur within a week of MTX administration.
  • Anti-D immunoglobulin (RhoGAM)
  • Alternative: expectant management

Surgery

  • Indications
    • Hemodynamic instability, impending rupture
    • Risk factors for rupture
    • Contraindications for MTX treatment: e.g., renal insufficiency
    • If conservative treatment is unsuccessful
    • If a concurrent surgical procedure is required, e.g., permanent sterilization
    • Patient's desire for a short duration of treatment and less follow-up
  • Laparoscopic removal
    • Salpingostomy (tube‑conserving operation)
      • Risk of persistent ectopic pregnancy
      • Patients with unruptured tubal pregnancy who do not meet the criteria for conservative treatment
    • Salpingectomy (not function-preserving)
      • Ruptured tube, heavy bleeding, large ectopic mass
      • If the patient does not desire future pregnancies → bilateral salpingectomy

References:[29][30][31][32][33][34][35][36]

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last updated 09/03/2018
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