History

Fact Explanation
Asymptomatic [3] Ectopic pregnancies can be asymptomatic until either symptoms of early pregnancy or complications occur.
Clinical triad of abdominal pain, amenorrhea, and vaginal bleeding [3] This presentation is relatively rare. [1]
Symptoms common to early pregnancy Patients may have amenorrhea, nausea, tenderness of breasts, and back pain. [4]
Symptoms of Shock [4] Secondary to hemorrhage caused by the rupture of the containing viscera.
Per vaginal bleeding [4] Doesn't necessarily correlate with the severity of hemorrhage.
Abdominal or pelvic pain [4] Abdominal pain is usually colicky in type. Pelvic pain is mostly unilateral and occasionally diffused. [3]
References
  1. ALSULEIMAN SA, GRIMES EM. Ectopic pregnancy: a review of 147 cases. J Reprod Med. [online] Feb 1982;27(2):101-6. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7097661
  2. KURT T. B. Ectopic Pregnancy. N Engl J Med [online] 23 July 2009; 361:379-387. [viewed 13 April 2014] Available from: DOI: 10.1056/NEJMcp0810384
  3. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  4. JANET M. T., ALISON E. B., ROBERT M. G., Ectopic Pregnancy. JAMA. [online] 2012;308(8):829. [viewed 13 April 2014] Available from: doi:10.1001/jama.2012.6215.

Symptoms - of the Disease

Fact Explanation
Asymptomatic [1] Ectopic pregnancies can be asymptomatic until either symptoms of early pregnancy or complications occur.
Symptoms common to early pregnancy Patients may have amenorrhea, nausea, tenderness of breasts, and back pain. [2]
References
  1. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  2. JANET M. T., ALISON E. B., ROBERT M. G., Ectopic Pregnancy. JAMA. [online] 2012;308(8):829. [viewed 13 April 2014] Available from: doi:10.1001/jama.2012.6215.

Examination

Fact Explanation
Pelvic tenderness [4,5] Due to presence of the ectopic.
Adnexal mass, or tenderness [5] The ectopic may be felt as an adnexal mass. [7]
Peritoneal signs Diffuse abdominal tenderness guarding and rigidity are indicative of ruptured ectopic. [3]
Cervical motion tenderness This is a specific finding but not diagnostic of ectopic pregnancy. [5]
Enlarged uterus But it is usually less than eight weeks of period of amenorrhea. [5]
Signs of shock [3] These include tachycardia, low blood pressure, narrow pulse pressure and cold clammy extremities. [3]
Pulse rate Usually tachycardia is present. but maybe absent in shock following rupture[1]
References
  1. ABBOTT J, EMMANS LS, LOWENSTEIN SR. Ectopic pregnancy: ten common pitfalls in diagnosis. Am J Emerg Med. [online] Nov 1990;8(6):515-22. [viewed 15 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2222596
  2. HUCHON, CPANEL P, KAYEM G, et al. Is a Standardized Questionnaire Useful for Tubal Rupture Screening in Patients With Ectopic Pregnancy?. Acad Emerg Med. Jan 5 2012; 19 (1) 24–30. [viewed 15 April 2014] Available from: DOI: 10.1111/j.1553-2712.2011.01238.x
  3. KURT T. B. Ectopic Pregnancy. N Engl J Med [online] 23 July 2009; 361:379-387. [viewed 13 April 2014] Available from: DOI: 10.1056/NEJMcp0810384
  4. JANET M. T., ALISON E. B., ROBERT M. G., Ectopic Pregnancy. JAMA. [online] 2012;308(8):829. [viewed 13 April 2014] Available from: doi:10.1001/jama.2012.6215.
  5. KALYANAKRISHNAN R., DEWEY C. S., Ectopic pregnancy: Forget the “classic presentation” if you want to catch it sooner. J Fam Pract. [online] 2006 May;55(05):388-395. [viewed 13 April 2014] Available from: http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=171368

Differential Diagnoses

Fact Explanation
Intra uterine pregnancy [3] Patients with intrauterine pregnancy can have amenorrhea and examination may reveal an enlarged uterus. Trans-vaginal ultrasound scan will aid in detection of intrauterine pregnancy.
Appendicitis Both can present with acute abdomen and can have signs of peritoneal irritation. [4,7]
Acute pelvic inflammatory disease [5,7] Patients can present with an acute abdomen. Presence of fever and a history of new and unprotected sexual relationship will aid in the diagnosis.
Hemorrhagic ovarian cyst This is also a cause for acute abdominal and pelvic pain in females of child bearing age. [6]
Spontaneous abortion or threatened abortion [1,2,3] Both have amenorrhea, vaginal bleeding and sometimes abdominal pain.
Ovarian torsion [7] Patients have abdominal pain, nausea and or vomiting. [8] Commonly occurs during the pregnancy.
Molar pregnancy This produces vaginal bleeding and passage of grape-like vescicles early in the pregnancy, abdominal pain can arise due to large theca lutein cyst and symptoms of pregnancy may be exaggerated. On examination the uterus is large for dates. [9]
Ovarian tumor [2] Produces ovarian mass.
Endometriosis [7] Abdominal pain shows classic relationship with the menstrual cycle. The pain over-rides the period of menstruation.
References
  1. KURT T. B. Ectopic Pregnancy. N Engl J Med [online] 23 July 2009; 361:379-387. [viewed 13 April 2014] Available from: DOI: 10.1056/NEJMcp0810384
  2. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  3. KALYANAKRISHNAN R., DEWEY C. S., Ectopic pregnancy: Forget the “classic presentation” if you want to catch it sooner. J Fam Pract. [online] 2006 May;55(05):388-395. [viewed 13 April 2014] Available from: http://www.jfponline.com/index.php?id=22143&tx_ttnews[tt_news]=171368
  4. NGUYEN H., KHANH L., CONNIE L., HANH N., Concurrent Ruptured Ectopic Pregnancy and Appendicitis. J Am Board Fam Med [online] January 1, 2005: 18 (1) 63-66. [viewed 13 April 2014] Available from: doi: 10.3122/jabfm.18.1.63
  5. RICHARD L. S., Treatment of Acute Pelvic Inflammatory Disease. Infectious Diseases in Obstetrics and Gynecology. [online]2011: 2011: 13. [viewed 13 April 2014] Available from: http://www.hindawi.com/journals/idog/2011/561909/
  6. BASS IS, HALLER JO, FRIEDMAN AP, TWERSKY J, BALSAM D, GOTTESMAN R. The sonographic appearance of the hemorrhagic ovarian cyst in adolescents. J Ultrasound Med. [online] 1984;3:509–513. [viewed 13 April 2014] Available from: http://www.jultrasoundmed.org/content/3/11/509.long
  7. HYUCK J. C, SEUNG H. K., JUN Y. J. Ruptured Corpus Luteal Cyst: CT Findings. Korean J Radiol. [online] 2003 Jan-Mar; 4(1): 42–45. [viewed 13 April 2014] Available from: doi: 10.3348/kjr.2003.4.1.42
  8. EMMANUEL D. P., JEMMA J., JACKIE R. An update on the diagnosis and management of ovarian torsion. The Obstetrician & Gynaecologist [online] October 2012: 14 (4) 229–236. [viewed 13 April 2014] Available from: DOI: 10.1111/j.1744-4667.2012.00131.x
  9. ALESSANDRO C., SANTINA E., ROSA P. Management of molar pregnancy. J Prenat Med. [online] 2009 Jan-Mar; 3(1): 15–17. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/

Investigations - for Diagnosis

Fact Explanation
Serum and urine assays for the beta subunit of human chorionic gonadotropin (bhCG) Serum and urine contains increased amounts of bhCG during pregnancy.
Serum progesterone Progesterone level is lesser in an ectopic pregnancy than in a normal pregnancy. [6] In a nonviable pregnancy or an ectopic pregnancy serum progesterone are found in lesser amounts.
Ultrasonography [3,4] An intrauterine sack with or without fetal cardiac activity, during the scan is often adequate to exclude ectopic pregnancy. [1] However simultaneous presence of extra-uterine and intrauterine pregnancy (Heterotrophic Pregnancy) is also a possibility. Free liquid in the pouch of Douglas is also suggestive of an ectopic pregnancy. [6] Transvaginal ultrasonography gives higher resolution of images. Trans vaginal ultrasound when combined with serum bhCG estimation provides best way to diagnose an unruptured ectopic pregnancy. [2,5]
Diagnostic dilatation and curettage [5] The obtained curette does not show villi in an ectopic pregnancy. This is done with the purpose of diagnosis provided a non-viable pregnancy is confirmed by ultrasound scan and low level of bhCG or progesterone is present. [9]
Culdocentesis [7] This method is rarely used now. A needle is inserted in to the posterior fornix and to the cul-de-sac and blood is aspirated. If the aspirated blood is not clotting it is suggestive of an ectopic pregnancy.
Diagnostic laparoscopy Patients who are in pain or who are hemodynamically unstable are suitable candidates for a diagnostic laparoscopy. Once diagnosed laparoscopic salpingectomy or salpingostomy can also be done.
References
  1. STEIN JC, WANG R, ADLER N, BOSCARDIN J, JACOBY VL, WON G, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. [online] Dec 2010;56(6):674-83. [viewed 13 April 2014] Available from: http://www.annemergmed.com/article/S0196-0644(10)01196-0/abstract
  2. KURT T. B. Ectopic Pregnancy. N Engl J Med [online] 23 July 2009; 361:379-387. [viewed 13 April 2014] Available from: DOI: 10.1056/NEJMcp0810384
  3. Bradley WG, Fiske CE, Filly RA. The double sac sign of early intrauterine pregnancy: use in exclusion of ectopic pregnancy. Radiology [online] 1982;143:223-226. [viewed 13 April 2014] Available from: doi:10.1148/radiology.143.1.7063730
  4. HADLOCK FP, SHAH YP, KANON DJ, LINDSEY JV. Fetal crown-rump length: reevaluation of relation to menstrual age (5-18 weeks) with high-resolution real-time US. Radiology [online] 1992;182:501-505. [viewed 13 April 2014] Available from: doi:10.1148/radiology.182.2.1732970
  5. FARQUHAR CM.: Ectopic pregnancy. Lancet. [online] 2005;366:583–91. [viewed 13 April 2014] Available from: doi:10.1016/S0140-6736(05)67103-6
  6. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  7. ANTHONY M. H., JOHN S. Atypical ectopic pregnancy and culdocentesis. Canadian Family Physician [online] OCTOBRE 2001: 47. [viewed 13 April 2014] Available from: http://www.cfp.ca/content/47/10/2057.full.pdf
  8. GOVINDARAJAN MJ, RAJAN R: Heterotopic pregnancy in natural conception. J Hum Reprod Sci [online] 2008: 1(1):37-38. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700683/?tool=pubmed
  9. MCCORD ML, MURAM D, BUSTER JE, ARHEART KL, STOVALL TG, CARSON SA. Single serum progesterone as a screen for ectopic pregnancy: exchanging specificity and sensitivity to obtain optimal test performance. Fertil Steril [online] 1996; 66: 513-516. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed?cmd=Search&term=Fertil+Steril%5BJour%5D+AND+66%5BVolume%5D+AND+513%5Bpage%5D

Investigations - Fitness for Management

Fact Explanation
Blood type If transfusion is needed.
Serum electrolytes and creatinine [1] Renal function should be evaluated prior to the surgery
Chest X-ray If there is a history of lung disease. [2]
References
  1. Practice advisory for preanesthesia evaluation. An updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. [viewed 15 April 2014] Available from: http://www.guideline.gov/content.aspx?id=36197
  2. RUCKER L, FRYE EB, STATEN MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA [online]250(23):3209-11. [viewed 15 April 2014] Available from: doi:10.1001/jama.1983.03340230061032.

Investigations - Followup

Fact Explanation
Beta–human chorionic gonadotropin (β-HCG) Weekly monitoring should be done.[1] Falling levels of β-HCG [2] are suggestive of successful treatment or conservative management. If levels are rising even after surgical treatment methotrexate therapy can be planned as an adjunct to surgical treatment.
References
  1. ANNE-MARIE LOZEAU, BETH POTTER. Diagnosis and Management of Ectopic Pregnancy. Am Fam Physician. [online] 2005 Nov 1;72(9):1707-1714. [viewed 15 April 2014] Available from: http://www.aafp.org/afp/2005/1101/p1707.html
  2. LAURIE M. I., MALCOLM L. P. Serial serum HCG measurements in a patient with an ectopic pregnancy: a case for caution. Human Reproduction [online] 2000: 15 (7) 1646-1647. [viewed 17 April 2014] Available from: http://humrep.oxfordjournals.org/content/15/7/1646.full.pdf?origin=publication_detail

Investigations - Screening/Staging

Fact Explanation
Transvaginal ultrasound scan Screening is not recommended routinely. However in patients with risk factors (history of ectopic pregnancy, history of tubal disease or surgery, pelvic inflammatory disease) screening enables early diagnosis and intervention. [1]
References
  1. MOL B, VAN DER VEEN F, BOSSUYT P. Symptom-free women at increased risk of ectopic pregnancy: should we screen?. Acta Obstet Gynecol Scand [online] 2002; 81: 661-672. [viewed 15 April 2014] Available from: DOI: 10.1034/j.1600-0412.2002.810713.x

Management - Specific Treatments

Fact Explanation
Expectant management Patients who are asymptomatic and without any evidence of rupture or hemodynamic instability are suitable candidates for expectant management. Serum beta–human chorionic gonadotropin levels should be assessed regularly and declining beta–human chorionic gonadotropin (β-HCG) levels suggests vanishing ectopic pregnancy.
Methotrexate A chemotherapeutic agent. Patient must be hemodynamically stable, fetal cardiac activity should be absent with no evidence of tubal rupture. [3] This is also used as an adjuvant therapy after surgery.
Surgical management Laparoscopic approach is preferred. [1] Either a linear salpingostomy or salpingectomy is done. Laparotomy is preferred if the patient is hemodynamically stable. [2,4]
References
  1. MOL F, MOL BW, ANKUM WM, VAN DER VEEN F, HAJENIUS PJ. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update [online] 2008;14:309-319. [viewed 13 April 2014] Available from: doi:10.1093/humupd/dmn012
  2. KURT T. B. Ectopic Pregnancy. N Engl J Med [online] 23 July 2009; 361:379-387. [viewed 13 April 2014] Available from: DOI: 10.1056/NEJMcp0810384
  3. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 13 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  4. JANET M. T., ALISON E. B., ROBERT M. G., Ectopic Pregnancy. JAMA. [online] 2012;308(8):829. [viewed 13 April 2014] Available from: doi:10.1001/jama.2012.6215.