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An ectopic pregnancy is a key differential for abdominal pain in a woman of childbearing age. It can represent a gynaecological emergency, so it is important that clinicians are aware of the symptoms, signs and management of this condition.

Ectopic pregnancy occurs in 1-2:100 pregnancies.


What is an ectopic pregnancy?

An ectopic pregnancy is often thought of as being a pregnancy that implants and develops outside of the uterus; however, it is more accurate to define it as a pregnancy that implants and develops outside of the endometrium.

Ectopic pregnancies are classified by the anatomical site of the implantation of the pregnancy (listed here from most to least common):

  • Ampullary ectopic – 64%
  • Fallopian isthmus ectopic – 25%
  • Fallopian infundibular ectopic – 9%
  • Interstitial ectopic (implantation in the interstitium where the Fallopian tube meets the uterus) – 1-2%
  • Ovarian ectopic – 0.5%
  • Cervical ectopic – 0.4%
  • Other – <1% (1)

Ectopics can occur in the myometrium where a fertilised ovum implants in a Caesarean section scar. There have been isolated cases of ectopic pregnancies as far afield as in the liver.


Risk factors

Risk factors include:

  • History of infertility or assisted conception
  • History of pelvic inflammatory disease (PID)
  • History of endometriosis
  • Previous pelvic or tubal surgery
  • Previous ectopic – estimated 10-20% recurrence

It is important to note that many women with an ectopic pregnancy will not have any obvious risk factors.


Symptoms and signs

Symptoms include:

  • Abdominal or pelvic pain – can be diffuse or localised to the left or right iliac fossa
  • Shoulder tip pain
  • Spotting or brown discharge
  • 6-8 weeks of amenorrhea
  • Other symptoms of pregnancy, such as nausea and breast tenderness
  • Dysuria
  • Symptoms of haemodynamic instability

 

Signs that may be elicited on examination:

  • Abdominal or pelvic tenderness
  • Cervical motion excitation
  • Adnexal mass
  • Signs of haemodynamic instability – tachycardia, low BP, postural hypotension

Investigations

  • Pregnancy test – any woman of childbearing age with abdominal symptoms (usually done routinely in A&E)
  • Bedside observations should be monitored frequently to ensure the patient is not developing signs of haemodynamic instability as this can indicate an ectopic rupture
  • A serum hCG should be sent alongside routine bloods as this can guide management
  • Transvaginal ultrasound is the gold standard for diagnosis – this is usually done in an Early Pregnancy Unit or similar

Management

Initial ABCDE assessment

If you suspect an ectopic pregnancy and the patient is haemodynamically unstable they should be referred for urgent assessment by the local gynaecology team. You should adopt an ABCDE approach to assessing and performing initial resuscitation (if in the community, urgent transfer to hospital should be arranged).

Expectant management

New guidelines brought out this year suggest that ectopic pregnancies can be managed expectantly under strict conditions: ³

  1. The patient is clinically stable and pain-free
  2. The pregnancy is <35mm with no heartbeat
  3. Serum hCG is <1000 IU/L
  4. The patient is able to re-present for follow up or in an emergency*

*It is extremely important that women are able to understand the significance of the condition and have the ability to re-attend for follow up if their symptoms worsen. Factors such as English as a second language, learning difficulties or any other impediment to coming back to a hospital are considered risk factors and indicate that more active management is likely required.

Serum hCG should be taken on days 2, 4 and 7 after presentation to ensure it is decreasing.

 

Medical management

Medical management of ectopic pregnancy can be used in patients where the following conditions are met:

  1. No significant pain
  2. The pregnancy is <35mm with no heartbeat
  3. Serum hCG is <1500 IU/L
  4. The patient is able to re-present for follow up or in an emergency

Medical management is by systemic methotrexate, so it’s important to be sure that there is no concurrent viable intrauterine pregnancy present, as methotrexate is teratogenic.

Serum hCG should be taken on day 4 and 7 of treatment to ensure it is dropping.

 

Surgical management

Surgical management should be considered when:

  1. There are signs of haemodynamic instability or significant pain
  2. The pregnancy is >35mm and/or heartbeat present
  3. Serum hCG is >1500 IU/L
  4. The patient is unable to attend for follow up

Unless it’s an emergency, these surgeries are usually done laparoscopically.

Salpingectomy is the removal of the ectopic pregnancy along with the Fallopian tube. It is the preferred option in women who have no other risks to their fertility, as it reduces the likelihood of a repeat ectopic pregnancy. It can affect future fertility, so women should be carefully counselled about the pros and cons of the procedure.

Salpingotomy is an alternative that seeks to remove the ectopic pregnancy whilst preserving the Fallopian tube. It is usually offered to women who have other fertility issues, such as damage to the other Fallopian tube. It does carry a greater risk of a future ectopic pregnancy than salpingectomy.


A word on psychological support

Whilst an ectopic pregnancy is a potentially life-threatening situation for a woman, it is important to also acknowledge that the removal of an ectopic pregnancy also represents the loss of what may be a much longed for pregnancy. Women should be offered the same emotional support as anyone who has experienced an early pregnancy loss.

For women who have undergone a salpingectomy, there may be further emotional support needed to allow them to come to terms with the potential impact on their future fertility.

The Ectopic Pregnancy Trust website has some useful resources for patients and professionals.


References

  1. Panagiotis et al. (2011). Differential Diagnosis of Ectopic Pregnancy – Morbidity and Mortality. 10.5772/22704.
  2. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. (2008) The Oxford Handbook of Obstetrics and Gynaecology, 3rd Edition pp. 534-537
  3. NICE Guideline N126. Ectopic pregnancy and miscarriage: diagnosis and initial management (April 2019). Accessed at [LINK]

 

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