From the Guidelines
Ectopic pregnancy occurs in approximately 1-2% of all pregnancies, but can be as high as 13% in symptomatic emergency department patients. This condition happens when a fertilized egg implants outside the uterine cavity, most commonly in the fallopian tube (about 95% of cases) 1. Risk factors that increase the likelihood include previous pelvic inflammatory disease, prior ectopic pregnancy, history of tubal surgery, use of intrauterine devices, smoking, and advanced maternal age. Ectopic pregnancies cannot develop normally and require prompt medical attention as they can cause life-threatening bleeding if the fallopian tube ruptures.
Key Points
- Symptoms typically appear between weeks 4 and 12 of pregnancy and may include abdominal pain (often one-sided), vaginal bleeding, and missed menstrual periods.
- Diagnosis involves blood tests for pregnancy hormones and ultrasound imaging.
- Treatment options depend on how far the pregnancy has progressed and may include medication (methotrexate) to stop cell growth or surgical intervention, particularly in cases of rupture or when medication isn't appropriate.
- Early detection significantly improves outcomes, so anyone experiencing symptoms of possible ectopic pregnancy should seek immediate medical care. Some studies have shown that bedside ultrasound performed by emergency physicians can be used as a screening tool for ectopic pregnancy, with a high sensitivity for detecting the absence of an intrauterine pregnancy 1. However, the diagnostic utility of pelvic ultrasound is not limited by the discriminatory threshold, and ectopic pregnancies can present at almost any b-hCG level, high or low 1.
Recommendations
- Emergency physicians should consider ectopic pregnancy in the differential diagnosis of any woman of childbearing age presenting with abdominal pain or vaginal bleeding.
- Bedside ultrasound should be used as a screening tool for ectopic pregnancy in symptomatic patients, but the results should be interpreted in the context of the patient's clinical presentation and b-hCG level.
- Patients with indeterminate ultrasounds or a pregnancy of unknown location should be risk-stratified based on their initial b-hCG level and clinical presentation, and managed accordingly 1.
From the Research
Prevalence of Ectopic Pregnancy
- Ectopic pregnancy accounts for 1-2% of all pregnancies 2, 3, 4
- The incidence of extrauterine pregnancy has increased from 0.5% thirty years ago to a present day 1-2% 3
- In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2% 4
Characteristics of Ectopic Pregnancy
- 90% of ectopic pregnancies implant in the fallopian tube 2
- Abdominal ectopic pregnancy is a rare form of ectopic pregnancy, occurring in <1% of cases 2
- Risk factors for ectopic pregnancy include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility 4
Diagnosis and Management
- The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa 4
- Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management 4, 5, 6
- Laparoscopy is an effective approach for surgical treatment of ectopic pregnancy, with advantages including short hospital stay, low cost, and less adhesion formation 5, 6