Ectopic pregnancies should always be considered in any patient of reproductive age with vaginal bleeding +/- abdominal pain.
The most common presentation of ectopic pregnancy is usually first-trimester vaginal bleeding and/or abdominal pain. This may be associated with normal pregnancy discomforts (breast tenderness, frequent urination, nausea).
Vaginal bleeding: varied but usually preceded by a period of amenorrhoea.
Abdominal pain: varied but may be diffuse or localised and usually localised in the pelvis. Sudden onset of pain may be associated with tubal rupture. Shoulder pain may be associated with bleeding irritating the diaphragm.
It is also important to remember ectopic pregnancies may also present asymptomatically.
Previous ectopic pregnancy
Prior tubal pathology
Previous surgery (e.g. pelvic inflammatory disease, tubal ligation)
Current use of IUD or IVF
Note>50% of patients do not have an identifiable risk factor for pregnancy.
B-Hcg + Transvaginal/Transabdominal US
B-Hcg > 1500 – Should be able to see gestational sac on US
B-Hcg < 1500 – Continue serial monitoring 48h. If it continues to rise/plateau, it would be concerning for an ectopic pregnancy
If stable, B-hcg <1500
Monitor serum B-hcg every 48 hours until it reaches 0
If compliant, B-hcg <5000, mass < 3.5cm, no fetal heart rate
IM Methotrexate (single dose or more)
Measure B-Hcg on Day 4 or Day 7 for 15% drop in B-Hcg
Monitor serum B-hcg until it reaches 0
Contraindicated in renal/hepatic failure, breastfeeding, immunodeficiency, peptic ulcer disease
If medical management is contraindicated, poor compliance, B-hcg >5000, mass >3.5cm present fetal heart rate