Ectopic Pregnancy

Related Subjects: |Ectopic Pregnancy

⚠️ Ectopic pregnancy must be suspected in any woman of reproductive age with a positive pregnancy test, amenorrhoea, lower abdominal/pelvic pain, or abnormal vaginal bleeding. Delayed diagnosis can be life-threatening.

📖 Overview

• 🚺 Leading cause of maternal death in the first trimester.
• 💡 Classic triad: positive β-HCG, amenorrhoea, empty uterus on ultrasound.
• 🧪 Normal early pregnancy: serum β-HCG doubles approximately every 48 hours. Plateauing or slow rise is suspicious for ectopic.
• ⚠️ Avoid routine digital vaginal examination until resuscitation is available, as manipulation can precipitate rupture.

🧬 Aetiology & Sites

• Implantation of the embryo outside the uterine cavity.
• 📍 ~90% occur in the fallopian tube (most commonly ampullary region); others: cervical, interstitial, ovarian, abdominal.
• Incidence: ~1 in 200 pregnancies; risk increases with maternal age.

⚡ Risk Factors

• Previous ectopic pregnancy
• Pelvic inflammatory disease (PID), endometriosis, prior tubal surgery
• Use of IUCD
• Fertility treatments: IVF, reversal of sterilisation
• Ovarian/uterine cysts or tumours
• Smoking 🚬

🩺 Clinical Features

• Pre-rupture: Amenorrhoea (5–8 weeks post-LMP), unilateral sharp lower abdominal pain, light PV bleeding (“prune-juice” colour), nausea, breast tenderness.
• Post-rupture: Hypotension, tachycardia, syncope, shoulder-tip pain (diaphragmatic irritation), peritonitis → emergency.
• Vasovagal episodes and collapse may be initial presentation in some cases.

🔬 Investigations

• 🧪 Serum β-HCG: Serial measurement; plateau or suboptimal rise suggests ectopic.
• 🔎 Transvaginal ultrasound: Empty uterus, adnexal mass, free fluid in pelvis or pouch of Douglas.
• 💉 Rhesus typing: Anti-D prophylaxis indicated for Rh-negative women.
• 🩺 Laparoscopy: definitive diagnosis if imaging and β-HCG are inconclusive.
• Additional: CBC, blood group, renal and liver function if planning methotrexate.

🔍 Differential Diagnosis

• Acute appendicitis
• Acute PID or tubo-ovarian abscess
• Threatened, incomplete, or missed miscarriage
• Ovarian torsion

💊 Management

• Medical (stable, unruptured):
  • Methotrexate single-dose protocol: for β-HCG <1500 IU/L, mass <4 cm, no fetal cardiac activity, and hemodynamically stable.
  • Monitor β-HCG at day 4 and day 7; expect ≥15% fall between measurements. Repeat weekly until negative.
  • Side effects: nausea, stomatitis, fatigue; counsel on avoiding alcohol and folic acid supplementation.
• Surgical:
  • Laparoscopy: salpingotomy (preserve tube) or salpingectomy (remove tube) for stable patients.
  • Emergency laparotomy + salpingectomy if unstable, ruptured, or peritonitic.
• Conservative / expectant:
  • Small (<2 cm), asymptomatic masses, β-HCG <1000 IU/L.
  • Serial β-HCG and ultrasound; decline ≥15% per week expected.
• Supportive:
  • IV fluids and blood transfusion if hypotensive or shocked.
  • Anti-D prophylaxis for Rh-negative women (250 IU IM) if indicated.
  • Referral to Early Pregnancy Assessment Unit (EPAU) for follow-up until β-HCG negative.

📚 NICE & RCOG References

• RCOG Green-top Guideline: Ectopic Pregnancy
• NICE Guideline: Ectopic Pregnancy and Miscarriage