Ectopic Pregnancy

• Peak incidence in first trimester, most commonly 6–8 weeks from last menstrual period.
• Most ectopics are tubal (ampullary); rupture causes intra-abdominal haemorrhage and shock.
• Early diagnosis and gynae involvement reduce morbidity and mortality.

1. Check vitals, ABC. If shocked (tachycardia, hypotension, pallor, syncope) → resuscitate and call gynae immediately.
2. Confirm pregnancy: urine or serum β-hCG in all reproductive-age women with pain/bleeding.
3. Take focused history (LMP, pain onset and site, bleeding amount, risk factors, contraception, previous ectopic or PID).
4. Examine:
   • Abdomen – tenderness, guarding, rebound, distension.
   • Pelvic exam if appropriate – cervical motion tenderness, adnexal mass, uterine size, amount of bleeding.
5. Send baseline bloods: FBC, U&E, group & save ± cross-match, ± coagulation; consider ABG if unwell.
6. Perform ultrasound (ideally transvaginal) as soon as feasible:
   • Intrauterine pregnancy (IUP) seen → ectopic unlikely but heterotopic still possible in IVF/high-risk.
   • No IUP + positive β-hCG → pregnancy of unknown location (PUL) → ectopic until proven otherwise.
7. Unstable or high suspicion of rupture at any point → urgent gynae consult for surgical management.
8. Stable PUL → arrange serial β-hCG and repeat scan in collaboration with gynae/early pregnancy clinic.

Ectopics can occur in patients with no risk factors, but risk is higher in:

• Previous ectopic pregnancy.
• Previous tubal surgery or tubal ligation / reconstruction.
• Pelvic inflammatory disease, chlamydia or other STIs causing tubal damage.
• Infertility and assisted reproductive techniques (e.g. IVF).
• Current or recent IUD use (if pregnancy occurs despite IUD, ectopic risk is higher).
• Smoking.
• Advanced maternal age (> 35 years).
• History of spontaneous or induced abortion (often reflecting underlying tubal pathology).

Presentation is often subtle and variable. Maintain a high index of suspicion.

• Classic triad: missed/late period + lower abdominal pain + vaginal bleeding (but all three may not be present).
• Unilateral pelvic pain, often crampy or sharp.
• Light to moderate vaginal bleeding or brown discharge.
• Shoulder tip pain or diaphragmatic irritation if significant intra-abdominal blood.
• Dizziness, pre-syncope, syncope – especially if rupture and blood loss.
• On exam: adnexal tenderness or mass, cervical motion tenderness, uterine size smaller than expected.

• β-hCG (serum):
  • Confirms pregnancy and helps interpret ultrasound.
  • In a viable IUP, β-hCG should typically rise appropriately over 48 hours; plateauing or slow rise raises concern for ectopic or failing pregnancy.
• Transvaginal ultrasound (TVUS):
  • Preferred imaging modality – detects IUP, adnexal mass, yolk sac, fetal pole, free fluid.
  • Absence of IUP when β-hCG is above the local “discriminatory zone” (often around 1500–2000 IU/L) is highly suspicious for ectopic or PUL.
• Abdominal ultrasound: less sensitive but useful where TVUS unavailable – look for free fluid, obvious adnexal mass.
• Serial β-hCG measurements: especially important in stable PUL – rising, falling, or plateauing patterns guide further management.
• Laparoscopy: definitive diagnosis and treatment when imaging is inconclusive and suspicion remains high, or when patient is unstable.

1. Haemodynamically Unstable / Ruptured Ectopic

• Immediate ABC assessment; high-flow oxygen.
• Two large-bore IV lines; send bloods including cross-match.
• Fluid resuscitation with crystalloid while arranging blood products.
• Activate massive transfusion if major haemorrhage suspected.
• Urgent gynae consult – emergency laparotomy/laparoscopy for haemostasis and removal of ectopic.
• Keep NBM; prepare for theatre; continuous monitoring.

2. Haemodynamically Stable – Surgical vs Medical

• Surgical options: laparoscopy (salpingostomy or salpingectomy) or laparotomy depending on local resources and patient factors.
• Medical management (methotrexate): usually considered when:
  • Patient is stable and reliable for follow-up.
  • No evidence of rupture or significant haemoperitoneum.
  • β-hCG relatively low (local cut-off varies; often < 5000 IU/L).
  • No fetal cardiac activity and small ectopic size on TVUS.
  • No contraindications to methotrexate (e.g. liver disease, breastfeeding, immunodeficiency, renal failure).
• Methotrexate protocols and follow-up schedules are usually managed by gynae/early pregnancy services.

3. Pregnancy of Unknown Location (PUL)

• Positive pregnancy test + no IUP or ectopic seen on scan.
• Stable patients can often be managed as outpatient with:
  • Serial β-hCG (typically 48-hour intervals).
  • Repeat TVUS as arranged by gynae/early pregnancy clinic.
• Provide clear written instructions and emergency return advice.

• Immediate complications: haemorrhagic shock, need for transfusion, anaesthetic risk.
• Long-term concerns: reduced fertility (especially after salpingectomy), risk of recurrent ectopic, psychological impact.
• Patients treated with methotrexate:
  • Require repeated β-hCG monitoring until undetectable.
  • Must avoid pregnancy and folate supplements until cleared by gynae.
• All patients should receive clear follow-up plans with gynae/early pregnancy services.

• Explain in simple terms what an ectopic pregnancy is and why it cannot continue safely.
• Emphasise the risk of rupture and need for urgent treatment – this is about protecting the patient’s life.
• Discuss:
  • Which treatment was chosen (surgical vs medical) and why.
  • Expected symptoms and side-effects.
  • When to seek urgent care – worsening pain, dizziness, collapse, heavy bleeding.
• Acknowledge emotional impact and offer support / referral for counselling if available.
• Discuss future pregnancy planning and the importance of early assessment in subsequent pregnancies.