Ectopic Pregnancy

Anatomy
The majority of ectopic pregnancies occur in the ampullary or isthmic portions of the Fallopian
tubes. About 2-5% occur as interstitial (cornual) ectopic pregnancies. The rare remaining
locations include cervical, fimbrial, ovarian, and peritoneal sites, as well as previous caesarean
section scars. There are a few documented cases of viable pregnancy outside the uterus and tubes
but, as a general rule, only an intrauterine pregnancy is viable.

Risk factors
One third of women with ectopic pregnancies do not have risk factors.

Fertility treatments and intrauterine contraceptive devices (IUCDs) are the most
important associated risk factors.[2]

Pelvic inflammatory disease may cause complete tubal occlusion or delay the transport of
the embryo so that implantation occurs in the tube. Adhesions from infection and
inflammation from endometriosis may play a part.

Ectopic pregnancy has been reported in tubes that have been divided in a sterilisation
operation and where they have been reconstructed to reverse one.

Ectopic pregnancy can occur in the treatment of infertility.

Right-sided tubal pregnancy is more common than left-sided. This is thought to be from
spread of infection from appendicitis.

The ability of the tube to expand increases from medially to laterally. Hence, a more
lateral implantation will present later as either pain or rupture.

Where an IUCD or progestogen-only oral contraceptives, including emergency

contraception, fails, the risk of a pregnancy being ectopic is greater than with other forms
of contraception. Depot and implant contraception may not have the same risks. Ectopic
pregnancy has been reported with implant contraception with etonogestrel (Nexplanon)
but is rare.

History

Symptoms and signs of ectopic pregnancy can resemble those of other more common
conditions, including urinary tract infections and gastrointestinal conditions.

The most common symptoms are:[3]

o Abdominal pain.
o Pelvic pain.
o Amenorrhoea or missed period.
o Vaginal bleeding (with or without clots).

Other symptoms may include:

o Dizziness, fainting or syncope.
o Breast tenderness.
o Shoulder tip pain.
o Urinary symptoms.
o Passage of tissue.
o Rectal pain or pressure on defecation.

There may be a history of a previous ectopic pregnancy. After one ectopic pregnancy the
chance of another in the other tube is much increased.

If the ectopic pregnancy has ruptured, bleeding is profuse and there may be features of
hypovolaemic shock, including feeling dizzy on standing. Most bleeding will be into the
pelvis and so vaginal bleeding may be minimal and misleading.

Diarrhoea and vomiting are possible, atypical clinical features of ectopic pregnancy

Early pregnancy assessment services

Regional services should be organised so that an early pregnancy assessment service
is available 7 days a week for women with early pregnancy complications, where
scanning can be carried out and decisions about management made.

Symptoms and signs of ectopic pregnancy and initial

assessment
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.
All healthcare professionals involved in the care of women of reproductive age should
have access to pregnancy tests.

Using ultrasound for diagnosis

Offer women who attend an early pregnancy assessment service (or out-of-hours
gynaecology service if the early pregnancy assessment service is not available) a
transvaginal ultrasound scan to identify the location of the pregnancy and whether there
is a fetal pole and heartbeat.

Human chorionic gonadotrophin measurements in

women with pregnancy of unknown location
Be aware that women with a pregnancy of unknown location could have an ectopic
pregnancy until the location is determined.

Expectant management
Use expectant management for 714 days as the first-line management strategy for
women
with a confirmed diagnosis of miscarriage. Explore management options other than
expectant management if:
the woman is at increased risk of haemorrhage (for example, she is in the late first
trimester) or she has previous adverse and/or traumatic experience associated with
pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or
she is at increased risk from the effects of haemorrhage (for example, if she has
coagulopathies or is unable to have a blood transfusion) or

Physical Examination

There may be some tenderness in the suprapubic region.

Peritonism and signs of an acute abdomen may occur.

Women with a positive pregnancy test and any of the following need to be referred
immediately to hospital:
o Pain and abdominal tenderness.

o Pelvic tenderness.
o Cervical motion tenderness.
The physical examination of patients with ectopic pregnancy is highly variable and often
unhelpful. Patients frequently present with benign examination findings, and adnexal masses are
rarely found. Patients in hemorrhagic shock from ruptured ectopic may not be tachycardic.[49]
Some physical findings that have been found to be predictive (although not diagnostic) for
ectopic pregnancy include the following:

Presence of peritoneal signs

Cervical motion tenderness

Unilateral or bilateral abdominal or pelvic tenderness - Usually much worse

on the affected side

Abdominal rigidity, involuntary guarding, and severe tenderness, as well as evidence of

hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the
clinician to a surgical emergency; this may occur in up to 20% of cases. However, midline
abdominal tenderness or a uterine size of greater than 8 weeks on pelvic examination decreases
the risk of ectopic pregnancy.[50]
On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical
motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is
usually difficult to differentiate from the ipsilateral ovary.
The presence of uterine contents in the vagina, which can be caused by shedding of endometrial
lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an incomplete or
complete abortion and therefore a delayed or missed diagnosis of ectopic pregnancy.

Investigations

The most accurate method to detect a tubal pregnancy is transvaginal

ultrasound.

This can identify the location of the pregnancy and also whether there
is a fetal pole and heartbeat.

Human chorionic gonadotrophin (hCG) levels are performed in women

with pregnancy of unknown location who are clinically stable.

hCG levels are taken 48 hours apart. If there is a change in

concentration between 50% decline and 63% rise inclusive over 48
hours then the woman should be referred for clinical review in an early
pregnancy assessment service within 24 hours.

Management

Admit as an emergency if the diagnosis of ectopic pregnancy is

considered a possibility. A bedside pregnancy test should be performed
on all women of childbearing age presenting with lower abdominal pain
where pregnancy is even the remotest possibility.

Anti-D rhesus prophylaxis should be given (at a dose of 250 IU) to all
rhesus negative women who have a surgical procedure to manage an
ectopic pregnancy. Women who receive medical treatment for their
ectopic pregnancy do not need to receive it.

All women should be given written information which is tailored to their

care. They should also be given a 24-hour contact telephone number to
use if their symptoms worsen or new symptoms develop.

Early pregnancy assessment units should accept self referrals from

women with a history of ectopic pregnancy.

Conservative management may be appropriate if the levels of hCG are

falling and the patient is clinically well. Repeat hCG levels are
performed in these cases.