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

Before you go have another look at the clinical case and see have any of your answers to the questions changed?