Written by Professor James Walker, April 2002

Be Aware:

• Bleeding in early pregnancy - consider an ectopic pregnancy and refer to an early pregnancy unit;

• Exclusion of ectopic pregnancy cannot be made in the community;

• Assume a women is pregnant until a pregnancy test is found to be negative;

• Waiting to see if the symptoms settle can put the woman at great danger by increasing morbidity and mortality;

• Atypical presentations occur so do not expect bleeding in all cases;

• Refer if in any doubt for further investigation;

• Emergency admission is justified because of the potentially serious consequences.

Incidence

The incidence of ectopic pregnancy is increasing and has doubled in the last twenty years. Of the nearly three million pregnancies in the UK in 1997-99, 31946 were ectopic*, giving an incidence of around one per cent (11.1 per 1000 pregnancies in 1997-99*). Although the incidence has increased, the death rate has remained at around 1/250 ectopic pregnancies over the last ten years. Deaths in early pregnancy are now the second most common direct cause of maternal death, higher than both haemorrhage and hypertension*. The majority of these deaths are due to ectopic pregnancy (EP) which amount to over 4 deaths each year*. There is also a high rate of morbidity because of tubal damage leading to subfertility and pelvic pain.

* Report on Confidential Enquiries into Maternal Deaths in the United Kingdom, 2001

Awareness

Most cases of ectopic pregnancy first present to their general practitioner with non-specific symptoms of bleeding and/or pain. It is important to be aware of the possibility of ectopic pregnancy in all such women, since the exclusion of EP is difficult in the community. Any woman with unexplained abdominal pain and the possibility of an early pregnancy with or without vaginal bleeding should be considered to have an ectopic pregnancy until proven otherwise. A pregnancy test should always be done and, if positive, it is paramount to refer the women to the hospital immediately to allow the appropriate investigations and treatment to lessen the risks both to life and fertility.

Presentation

The presentation in 90% of cases is with a cramp like, colicky lower abdominal pain which can be either suprapubic or in the iliac fossa and this may be confused with appendicitis. The pain can be severe, may waken the patient and is worse on movement but it may be mild in nature and atypical. The pain usually precedes bleeding. There may be the classic shoulder tip pain felt particularly when the women lies down due to blood irritation of the diaphragm. In most cases (80%) there is a history of amenorrhoea and there is vaginal bleeding in 75% cases. This loss may be the classic brown blood (so called 'prune juice') or may be red and heavy and resemble a period. Gastrointestinal symptoms, notably diarrhoea and painful defecation may be present (the so called 'Bathroom sign', due to the presence of blood in the Pouch of Douglas). There may also be dizziness, light-headedness, nausea and vomiting and pallor. Unusual presentations are not uncommon and many patients present in a far from typical manner.

Examination

On examination the temperature, pulse and blood pressure are normal unless there has been rupture (present in 20% cases) in which case the there may be a tachycardia and/or hypotension. Sitting the women up can exacerbate this hypotension. Abdominal palpation may show some tenderness and pelvic examination (which is best avoided outside hospital) may produce acute excruciating pain on moving the cervix. The uterus may be enlarged with features of early pregnancy. Differential diagnosis includes salpingitis, appendicitis and torsion (twisting) of an ovarian cyst. The important feature suggestive of an EP is the possibility of pregnancy.

Investigation

A positive pregnancy test (using an early test such as the beta HCG tests, or estimation of serum HCG) will increase the suspicion whereas a negative early pregnancy test makes the diagnosis unlikely. Once referred the definitive investigation is an ultrasound scan. If this shows there to be a intrauterine pregnancy, this excludes an ectopic pregnancy except in the case of a heterotopic ectopic (an ectopic pregnancy in association with a intrauterine pregnancy) the incidence of which is less than 1 in 30000 but much higher in IVF pregnancies. In many cases, laparoscopy may be needed for definitive diagnosis

Treatment

All management of suspected ectopic pregnancy is under the care of specialised units. If an ectopic pregnancy is diagnosed, laparoscopic treatment may be possible which reduces the long term morbidity. Medical therapy with methotrexate is commonly used in the USA but it requires a sure diagnosis, which is often not possible. It is still necessary to carry out laparotomy in many cases because of the clinical situation or facilities available.

Summary

• In any woman of reproductive years presenting with abdominal pain with or without vaginal bleeding there should always be a suspicion of ectopic pregnancy;

• A sensitive pregnancy test should be arranged at once either by the general practitioner or by referral to hospital;

• A positive pregnancy test associated with low abdominal pain should always be considered a possible ectopic pregnancy even if there is no vaginal loss, and the patient should be referred to hospital for further investigation;

• If there are signs of shock (blood pressure is low and/or the pulse high) immediate emergency admission is mandatory without delay;

• Vaginal examination should not be carried out in the community because of the risk of tubal rupture and collapse. This should wait until the patient is in hospital.

Ectopic pregnancies are more likely in

• Women over the age of 35.

• Women of African descent.

• Women using:

  • Intrauterine contraceptive devices;

  • Combined oral contraceptive pill;

  • Progesterone only contraception;

  • Emergency hormonal contraception.

• Women with damaged tubes:

  • After a previous ectopic pregnancy;

  • After chlamydia infection or a history of pelvic pain;

  • After tubal sepsis or scarring;

  • After tubal surgery (including sterilisation);

  • Due to congenital abnormalities of the tube.

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