Ruptured Ectopic Pregnancy
Introduction
An ectopic pregnancy is and extra-uterine pregnancy, 98% of which occur in the fallopian tube.
Ectopic pregnancy is a potentially lethal condition due to rupture and haemorrhage. Therefore it is an important diagnosis that needs to be considered in all woman of child bearing age who present with PV bleeding or abdominal pain.
Risk Factors
Risk factors for ectopic pregnancy include;
Tubular pathology
previous ectopic pregnancy
Tubular surgery
Endometriosis
Pelvic inflammatory disease (PID)
Patient factors
smoker
Age > 35
Fertility treatments including IVF
If pregnancy occurs with an intra-uterine device in-situ there is a higher probability that the pregnancy will be ectopic
Clinical Features
Symptoms
Ectopic Pregnancies may be asymptomatic prior to rupture
Pelvic pain usually localised to one side. Tubal rupture is associated with abrupt onset of severe abdominal pain
Referred shoulder tip pain due to significant intra-peritoneal haemorrhage irritating the diaphragm
Sudden collapse/syncope
PV Bleeding
Recent amenorrhoea usually (6-8 weeks) - not universal, bleeding in early pregnancy is very common
Signs
Evidence of Haemorrhagic shock
hypotension
tachycardia
pallor
delayed cap refill
tachypnoea
Adnexal tenderness/Abdominal peritonism
Pelvic pain/tenderness often localised to one side
Adnexal tenderness +/- mass, cervical excitation on PV exam
Significant diffuse abdominal pain / tenderness / peritonism / distension suggests rupture + intra-abdominal bleeding
Differential Diagnosis
Ruptured ectopic pregnancy is a life threatening diagnosis. Consider differential diagnoses but the priority is out rule ectopic pregnancy first. Potential alternative diagnoses are listed below.
Gynaecology
Ruptured ovarian cyst
Haemorrhagic ovarian cyst
Pelvic inflammatory disease
Ovarian torsion
Gastro-intestinal
Appendicitis
Colitis
Inflammatory bowel disease
Diverticulitis
Acute pancreatitis
Acute biliary pathology
Other
Urosepsis
Ureteric Colic
Splenic artery aneurysm
Clinical Investigations
Bedside
Urinary beta HCG
point of care ultrasound - looking for intra-abdominal free fluid
Venous Blood Gas
high lactate / low pH concerning for haemorrhagic shock
Hb will be normal initially
Laboratory
Group and hold
Rhesus status - consider need for anti-D
Serum Hcg if urine hcg negative and suspicious for ectopic pregnancy
Also be useful to plan non-ruptured ectopic pregnancy management by gynae team
FBC
U/E
Coag
Radiology
Unstable patient
should never leave ED for an ultrasound
Clinical exam and POCUS should be sufficient
TVUS can be performed in ED by gynaecology if needed
Stable patients
Trans-vaginal ultrasound
Management and disposition
Initial Resuscitation
2 wide bore iv cannulae
If unstable activate massive transfusion protocol and transfuse O negative blood while awaiting type specific blood
Symptomatic treatement
Iv morphine for pain
Specific treatment
If concern for rupture ectopic needs emergent review by gynaecology in the ED
Unstable patients
transfer to theatre for salpingectomy
Stable patients
refer to gynaecology
if no rupture present options for medical (methotrexate)vs surgical management should by made by gynaecology team in conjunction with the patient
References
1. Togus Tulandi et al. Ectopic pregnancy: Epidemiology, risk factors and anatomic sites. Clinical manifestations and diagnosis. Up to Date website. Jan 2020.
This blog was written by Dr. Deirdre Glynn and was last updated in October 2020