Ectopic Pregnancy Clinical Presentation

  • Author: Vicken P Sepilian, MD, MSc; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Aug 2, 2012
 

History

The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding; unfortunately, only about 50% of patients present with all 3 symptoms. About 40-50% of patients with an ectopic pregnancy present with vaginal bleeding, 50% have a palpable adnexal mass, and 75% may have abdominal tenderness. In one case series of ectopic pregnancies, abdominal pain presented in 98.6% of patients, amenorrhea in 74.1% of them, and irregular vaginal bleeding in 56.4% of patients.[42]

These symptoms overlap with those of spontaneous abortion; a prospective, consecutive case series found no statistically significant differences in the presenting symptoms of patients with unruptured ectopic pregnancies versus those with intrauterine pregnancies.[43]

In first-trimester symptomatic patients, pain as the presenting symptom is associated with an odds ratio of 1.42, and moderate to severe vaginal bleeding at presentation is associated with an odds ratio of 1.42 for ectopic pregnancy.[44] In one study, 9% of patients with ectopic pregnancy presented with painless vaginal bleeding.[45] As a result, almost 50% of cases of ectopic pregnancy are not diagnosed at the first prenatal visit.

Patients may present with other symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia. Painful fetal movements (in the case of advanced abdominal pregnancy), dizziness or weakness, fever, flulike symptoms, vomiting, syncope, or cardiac arrest have also been reported. Shoulder pain may be reflective of peritoneal irritation.

Astute clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness.

Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. Fortunately, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed before rupture.

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Physical Examination

The physical examination of patients with ectopic pregnancy is highly variable and often unhelpful. Patients frequently present with benign examination findings, and adnexal masses are rarely found. Patients in hemorrhagic shock from ruptured ectopic may not be tachycardic.[46]

Some physical findings that have been found to be predictive (although not diagnostic) for ectopic pregnancy include the following:

  • Presence of peritoneal signs
  • Cervical motion tenderness
  • Unilateral or bilateral abdominal or pelvic tenderness - Usually much worse on the affected side

Abdominal rigidity, involuntary guarding, and severe tenderness, as well as evidence of hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases. However, midline abdominal tenderness or a uterine size of greater than 8 weeks on pelvic examination decreases the risk of ectopic pregnancy.[47]

On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary.

The presence of uterine contents in the vagina, which can be caused by shedding of endometrial lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an incomplete or complete abortion and therefore a delayed or missed diagnosis of ectopic pregnancy.

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Contributor Information and Disclosures
Author

Vicken P Sepilian, MD, MSc  Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center

Vicken P Sepilian, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ellen Wood, DO, FACOOG  Voluntary Assistant Professor, University of Miami, Leonard M Miller School of Medicine

Ellen Wood, DO, FACOOG is a member of the following medical societies: American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert K Zurawin, MD Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association

Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

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Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; and (G) Cervical, 0.2%.
Laparoscopic picture of an unruptured right ampullary tubal pregnancy; bleeding out of the fimbriated end has resulted in hemoperitoneum.
A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at Medical College of Pennsylvania and Hahnemann University (MCPHU).
A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at Medical College of Pennsylvania and Hahnemann University (MCPHU).
An endovaginal sonogram reveals an intrauterine pregnancy at approximately 6 weeks. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are depicted.
An endovaginal sonogram revealing a complex mass outside of the uterus, with a small yolk sac present within. The mass is more echogenic relative to the uterus above and represents an ectopic pregnancy.
An endovaginal sonogram demonstrates an early ectopic pregnancy. An echogenic ring (tubal ring) found outside of the uterus can be seen in this view.
A pseudogestational sac of ectopic pregnancy can be confused with embryonic demise. This sac is produced when an ectopic pregnancy stimulates the endometrium, with degeneration of the central decidual reaction.
Linear incision being made at the antimesenteric side of the ampullary portion of the fallopian tube.
Laparoscopic picture of an ampullary ectopic pregnancy protruding out after a linear salpingostomy was performed.
Schematic of a tubal gestation being teased out after linear salpingostomy.
 
 
 
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