An ectopic pregnancy is an extrauterine pregnancy.

The majority of ectopic pregnancies occur

in the fallopian tube (84 percent), but other possible sites include: cervical, interstitial (also
referred to as cornual; a pregnancy located in the proximal segment of the fallopian tube that is
embedded within the muscular wall of the uterus), hysterotomy (cesarean) scar, intramural,
ovarian, or abdominal. In addition, in rare cases, a multiple gestation may be heterotopic
(include both a uterine and extrauterine pregnancy).

The diagnosis of ectopic pregnancy is based upon a combination of measurement of the serum
quantitative human chorionic gonadotropin and findings on transvaginal ultrasonography.

The most common clinical presentation of ectopic pregnancy is first-

trimester vaginal bleeding and/or abdominal pain

Clinical manifestations of ectopic pregnancy typically appear six to eight

weeks after the last normal menstrual period, but may occur later,
especially if the pregnancy is at an extrauterine site other than the
fallopian tube.

An ectopic pregnancy may be unruptured or ruptured at the time of presentation to medical

care. Tubal rupture (or rupture of other structures in which an ectopic pregnancy is implanted)
can result in life-threatening hemorrhage. Any symptoms suggestive of rupture should be
noted. These include severe or persistent abdominal pain or symptoms suggestive of ongoing
blood loss (eg, feeling faint or loss of consciousness).

Pain associated with ectopic pregnancy is usually located in the pelvic area. It may be diffuse or
localized to one side. In cases in which there is intraperitoneal blood that reaches the upper
abdomen or in rare cases of abdominal pregnancy, the pain may be in the middle or upper
abdomen. If there is sufficient intraabdominal bleeding to reach the diaphragm, there may be
referred pain that is felt in the shoulder. Blood pooling in the posterior cul-de-sac (pouch of
Douglas) may cause an urge to defecate.

Risk factors for ectopic pregnancy should be elicited, including prior ectopic pregnancy, current
use of an intrauterine device, prior tubal ligation, and in vitro fertilization (IVF)

A salpingostomy involves making an incision into the tube over the site of the pregnancy and
removing the ectopic pregnancy with the goal of preserving the tube for future conceptions.

A complete pelvic examination should be performed. The speculum examination is used to

confirm that the uterus is the source of bleeding (rather than a cervical or vaginal lesion) and to
assess the volume of bleeding by noting the quantity of blood in the vagina and presence or
absence of active bleeding from the cervix.

A bimanual pelvic examination is performed; the examination is often unremarkable in a

woman with a small, unruptured ectopic pregnancy. Palpation of the adnexa should be
performed with only a small degree of pressure, since excessive pressure may rupture an
ectopic pregnancy. Findings on examination may include cervical motion, adnexal, and/or
abdominal tenderness. An extraovarian adnexal mass is noted in some women.

Cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy,
and appendicitis.

Entities frequently confused with ectopic pregnancy include salpingitis, threatened or

incomplete abortion, ruptured corpus luteum, appendicitis, dysfunctional uterine bleeding,
adnexal torsion, degenerative uterine leiomyoma, and endometriosis
Perform additional testing to guide further management (eg, blood type and antibody screen,
pretreatment testing for methotrexate therapy).

The initial test to diagnose pregnancy may be either a urine or serum hCG. Once a pregnancy is
confirmed, if ectopic pregnancy is suspected, the serum quantitative hCG is then repeated
serially (typically every two days) to assess whether the increase in concentration is consistent
with an abnormal pregnancy. In some cases, the diagnosis of ectopic pregnancy can be made
after a single measurement of hCG in combination with transvaginal ultrasound, if the hCG is
above the discriminatory zone and transvaginal ultrasound shows no evidence of an
intrauterine pregnancy and the presence of findings that suggest an ectopic pregnancy.

In pregnant women, hCG can be detected in serum and urine as early as eight days after the
luteinizing hormone surge (approximately 21 to 22 days after the first day of the last menstrual
period in women with 28-day cycles).

Perform additional testing to guide further management (eg, blood type and antibody screen,
pretreatment testing for methotrexate therapy).

Rupture should be suspected in women with a sudden onset of severe and persistent
abdominal pain, rapid uterine bleeding, symptoms of faintness, or vital signs suggestive of
hemodynamic compromise.

The abdominal examination is often unremarkable or may reveal lower abdominal tenderness.
If rupture with significant bleeding has occurred, the abdomen may be distended and diffuse, or
localized tenderness to palpation and/or rebound tenderness may be found on examination.

A complete pelvic examination should be performed. The speculum examination is used to

confirm that the uterus is the source of bleeding (rather than a cervical or vaginal lesion) and to
assess the volume of bleeding by noting the quantity of blood in the vagina and presence or
absence of active bleeding from the cervix.
A bimanual pelvic examination is performed; the examination is often unremarkable in a
woman with a small, unruptured ectopic pregnancy. Palpation of the adnexa should be
performed with only a small degree of pressure, since excessive pressure may rupture an
ectopic pregnancy. Findings on examination may include cervical motion, adnexal, and/or
abdominal tenderness. An extraovarian adnexal mass is noted in some women.

TVUS alone (without measurement of hCG) can exclude or diagnose an ectopic pregnancy only
if one of the following findings is present:
●Findings diagnostic of an IUP (ie, gestational sac with a yolk sac or embryo). However, in
women who conceived with ovulation induction or in vitro fertilization, a heterotopic
pregnancy may rarely occur.
●Findings diagnostic of a pregnancy at an ectopic site (gestational sac with a yolk sac or
embryo).

Gestational sac — The gestational sac of an early pregnancy may be

distinguished from other intrauterine fluid collections (including an
endometrial pseudosac) by the presence of the intradecidual sign and the
double decidual sign. However, these signs were defined with use of
transabdominal ultrasound. With transvaginal ultrasound, the
intradecidual sign or double decidual sign are absent in at least 35
percent of gestational sacs

The presence of a gestational sac without a yolk sac and/or embryo at specific sac size
thresholds is diagnostic of a missed abortion

Pseudosac — A pseudosac can be seen in up to 20 percent of women with an ectopic

pregnancy. A pseudosac is a small fluid collection that is centrally located within the
endometrial cavity and is surrounded by a thick decidual reaction (image 8) [24]. Differentiation
factors between a pseudosac and the intradecidual signs are that a pseudosac:
●Does not have an echogenic rim
●Tends to be located in the middle of the uterine cavity rather than embedded in the decidua
●Can change in shape during the scan
●May appear to be complex since it contains blood

The ultrasound examination is also used to evaluate whether rupture of the tube or other
structure has occurred. A finding of echogenic fluid (consistent with blood) in the pelvic cul-de-
sac and/or abdomen is consistent with rupture. However, a small amount of fluid is present in
many women and a small amount of blood may be present in other conditions (eg,
spontaneous abortion). A ruptured ovarian cyst is another condition that is common in
pregnant women and may result in a small or large amount of blood. Rupture is indicated by
ultrasound findings of free fluid (blood) in the abdominal cavity.

Patients who are being followed for suspected ectopic pregnancy should be counseled about
the risk of rupture and should be advised to call if symptoms associated with rupture occur.
These include the new onset of or a significant worsening of abdominal pain, vaginal
hemorrhage, or feeling faint. In addition, women with a suspected ectopic pregnancy should be
counseled about possible outcomes of the evaluation, including viable IUP or the end of a
pregnancy with treatment for ectopic pregnancy.

Curettage — The intrauterine location of a pregnancy is diagnosed with certainty if

trophoblastic tissue is obtained by uterine curettage. Obviously, the use of curettage as a
diagnostic tool is limited by the potential for disruption of a viable pregnancy. Moreover, false
negatives can occur: chorionic villi are not detected by histopathology in 20 percent of
curettage specimens from elective termination of pregnancy.

Historically, culdocentesis was used to detect blood in the posterior cul-de-sac; however, this
finding can be easily demonstrated with transvaginal ultrasound. Blood in the posterior cul-de-
sac may be from bleeding from an unruptured or ruptured tubal pregnancy, but it may also be
the result of a ruptured ovarian cyst. Therefore, a culdocentesis positive for blood is
nondiagnostic.