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
Miscarriage8.75
Acute appendicitis2.75
Ectopic pregnancy1
<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.

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.

Expectant managementMedical managementSurgical management
Size <30mmSize <35mmSize >35mm
UnrupturedUnrupturedCan be ruptured
AsymptomaticNo painSevere pain
No fetal heartbeatNo fetal heartbeatVisible fetal heartbeat
serum B-hCG <200IU/L and decliningserum B-hCG <1500IU/Lserum B-hCG >1500IU/L
Compatible if another intrauterine pregnancyNot suitable if intrauterine pregnancyCompatible 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