Introduction
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy.
Epidemiology
- Incidence: 40.00 cases per 100,000 person-years
- Peak incidence: 30-40 years
| Condition | Relative incidence |
|---|---|
| Miscarriage | 8.75 |
| Acute appendicitis | 2.75 |
| Ectopic pregnancy | 1 |
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Clinical features
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
- lower abdominal pain
- due to tubal spasm
- typically the first symptom
- pain is usually constant and may be unilateral.
- vaginal bleeding
- usually less than a normal period
- may be dark brown in colour
- history of recent amenorrhoea
- typically 6-8 weeks from the start of last period
- if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
- peritoneal bleeding can cause
- shoulder tip pain
- pain on defecation/tenesmus secondary to blood pooling in the pouch of Douglas
- dizziness, fainting or syncope may be seen
- symptoms of pregnancy such as breast tenderness may also be reported
Investigations
A pregnancy test will be positive.
The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
Management
Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department.
There are 3 ways to manage ectopic pregnancies. And the following criteria can help to guide you which method your patient will be able to have.
There are 3 ways to manage ectopic pregnancies. And the following criteria can help to guide you which method your patient will be able to have.
| Expectant management | Medical management | Surgical management |
|---|---|---|
| Size <30mm | Size <35mm | Size >35mm |
| Unruptured | Unruptured | Can be ruptured |
| Asymptomatic | No pain | Severe pain |
| No fetal heartbeat | No fetal heartbeat | Visible fetal heartbeat |
| serum B-hCG <200IU/L and declining | serum B-hCG <1500IU/L | serum B-hCG >1500IU/L |
| Compatible if another intrauterine pregnancy | Not suitable if intrauterine pregnancy | Compatible with another intrauterine pregnancy |
| Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed. | Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up. | Surgical management can involve salpingectomy or salpingotomy |