Obstetrics & Gynaecology
A 28 year old lady is brought to the Emergency Department after fainting at work following severe worsening pelvic pain for the last few hours. On examination she is tender in the left iliac fossa with rebound tenderness. She is apyrexial, her blood pressure is 95/50 mmHg and her heart rate is 105 beats per minute. Which of the following investigations would be most useful for this patient?
Answer:
In patients with a suspected ectopic pregnancy, arrange a urine pregnancy test. Refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment of women with a positive pregnancy test and the following on examination:- pain and abdominal tenderness or
- pelvic tenderness or
- cervical motion tenderness.
Ectopic Pregnancy
Obstetrics & Gynaecology
Last Updated: 12th February 2021
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.
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.
Risk factors for ectopic pregnancy include:
- Previous ectopic pregnancy
- History of pelvic inflammatory disease
- History of tubal or other pelvic surgery
- History of sterilisation or reversal of sterilisation
- History of infertility
- Assisted reproductive techniques
- Cigarette smoking
- Maternal age over 35 years
- Having multiple sexual partners
Complications
- Tubal rupture
- If an ectopic pregnancy is undiagnosed and untreated, spontaneous tubal abortion occurs in about 50% of cases. If the ectopic pregnancy persists and remains undiagnosed and untreated, the tube may rupture, causing intra-abdominal bleeding, haemodynamic instability, and maternal death. The time of rupture depends on the site of implantation and usually occurs after 6 weeks.
- Recurrent ectopic pregnancy
- The rate of recurrence of ectopic pregnancy is about 18.5%.
- Psychological effects
- Grief, anxiety, and depression are experienced by many women after pregnancy loss.
Clinical features
Suspect ectopic pregnancy in a woman who presents with any of the following:
- Common symptoms
- Abdominal or pelvic pain
- Amenorrhoea or missed period
- Vaginal bleeding
- Less common symptoms
- Breast tenderness
- Gastrointestinal symptoms (such as diarrhoea and/or vomiting)
- Dizziness, fainting or syncope
- Shoulder tip pain (due to diaphragmatic irritation)
- Urinary symptoms
- Passage of tissue
- Rectal pressure or pain on defaecation
Signs of ectopic pregnancy include:
- More common signs
- Pelvic tenderness
- Adnexal tenderness
- Abdominal tenderness
- Other reported signs
- Cervical motion tenderness
- Rebound tenderness or peritoneal signs
- Pallor
- Abdominal distension
- Enlarged uterus
- Tachycardia or hypotension
- Shock or collapse
- Orthostatic hypotension.
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 and
- 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
- Conditions that can cause 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
- Conditions that can cause 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 (due to torsion, rupture, or bleeding)
- Torsion of a fibroid
- Pelvic vein thrombosis
ED Management
In patients with a suspected ectopic pregnancy, arrange a urine pregnancy test.
Resuscitate immediately if the woman has signs of haemodynamic instability (including pallor, tachycardia, hypotension, shock, and collapse) or significant bleeding or pain.
Refer immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment of women with a positive pregnancy test and the following on examination:
- pain and abdominal tenderness or
- pelvic tenderness or
- cervical motion tenderness.
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
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.
After an ectopic pregnancy has been confirmed, treatment options include expectant management (watchful waiting), medical management, and surgery. The choice of treatment will depend on factors such as the haemodynamic stability of the woman, the site of implantation of the ectopic pregnancy, the risk of tubal rupture, serum hCG level, the level of pain the woman has, and the acceptability of the method of treatment to the woman.
- Expectant management is an option for a few women, including those who have minimal or no symptoms and are clinically stable. Active intervention will be considered if symptoms of ectopic pregnancy occur or if levels of serum hCG fail to decrease at an acceptable rate.
- Medical management involves the use of drug treatment, most commonly methotrexate. It is offered first line to women who are able to return for follow up and who have all of the following:
- No significant pain.
- An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
- Serum hCG level less than 1500 IU/L.
- No intrauterine pregnancy (as confirmed on an ultrasound scan).
- Surgery, by means of salpingectomy or salpingotomy, is performed laparoscopically or by open surgery. It is offered first line to women who are unable to return for follow up after methotrexate treatment or who have an ectopic pregnancy and any of the following:
- Significant pain.
- Adnexal mass of 35 mm or larger.
- Fetal heartbeat visible on an ultrasound scan.
- Serum hCG level of 5000 IU/L or more.
- A choice of either methotrexate or surgical management is offered to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/L and less than 5000 IU/L, are able to return for follow up, and meet all of the following criteria:
- No significant pain.
- An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
- No intrauterine pregnancy (as confirmed on an ultrasound scan).
- All women (except those who have had a salpingectomy) will be followed up according to local protocols to ensure that serum hCG levels decrease at an acceptable rate until non-pregnant levels are reached (this may take up to 6 weeks).
- Anti-D immunoglobulin is offered to all rhesus-negative women who have had surgical removal of an ectopic pregnancy.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
