Overview

• Pregnancy outside the uterus → 98% occur in fallopian tubes. Can occur in ovary, uterus, broad ligament or abdomen.
  • Most common location → Ampulla.
  • Highest risk of rupture → Isthmus.
• Aetiology → damaged tubes.
  • Risk Factors → PID, previous ectopic, endometriosis, IUD, smoking, IVF.

Making Diagnosis

Clinical Features

• Abdominal pain.
• 6-8 weeks of amenorrhoea +/- PV bleeding.
• Diarrhoea + Shoulder tip pain + Back pain.
  • Shoulder tip pain suggests peritoneal bleeding due to rupture.
• O/E → cervical excitation.
  • Cervical Excitation → ectopic pregnancy or PID.
• Dizziness → if ruptured, presents with circulatory collapse.

Investigations

• Pregnancy Test (abdo pain in woman of child-bearing age) → Speculum (inspect Os) → TVUSS (MAIN INVESTIGATION).
  • 1. Located Ectopic.
  • 2. Pregnancy of Unknown Location (PUL) → measure serial b-hCG (at 0 and 48 hrs).
    • PUL → positive pregnancy test but no evidence of pregnancy on ultrasound. Management is serial b-hCG measurements. In normal pregnancy, will double every 48 hours.
    • Need yolk sac and gestational sac to be viable IUP, otherwise PUL.
      • Rise >63% after 48 hours → intrauterine (normal) pregnancy. Repeat TVUSS in 1-2 weeks.
      • Rise <63% after 48 hours → ectopic pregnancy. 1/3 of PULs will likely be an ectopic. Review in EPAU <24 hrs.
      • Fall >50% after 48 hours → miscarriage. Expectant management, repeat pregnancy test after 2 weeks to confirm.
• USS ⇒
  • Tubal → ‘bagel’ sign, ‘blob’ sign.
  • Cervical → ‘barrel’ cervix, -ve sliding sign, below internal os.
• Work-Up → A-E Assessment, IV Access, Bloods, Serum b-hCG, group and save, TVUSS (when stable), NBM (in case of surgery).

Management Plan

• Expectant → haemodynamically stable and asymptomatic patient.
  • Should have serial hCG measurements (days 2, 4 and 7 after original test) until levels are undetectable.