Signs and Symptoms of Ectopic Pregnancy
The classic triad of signs and symptoms of ectopic pregnancy includes vaginal bleeding, abdominal pain, and amenorrhea, though patients may present with varying clinical pictures ranging from asymptomatic to hemodynamic instability. 1, 2
Common Clinical Presentations
Primary Symptoms
- Abdominal/pelvic pain (most common symptom)
- Usually unilateral and localized to one lower quadrant
- May be sharp, dull, or cramping in nature
- Can become generalized with rupture
- Vaginal bleeding (70-80% of cases)
- Typically lighter than normal menstrual bleeding
- Often dark in color
- Intermittent spotting pattern
- Amenorrhea (missed period)
- Usually 6-8 weeks from last menstrual period
- Some patients may not recognize missed period
Secondary Symptoms
- Shoulder pain (referred pain from blood irritating the diaphragm)
- Urge to have bowel movement (from pressure on rectum)
- Dizziness or lightheadedness
- Syncope (fainting)
- Breast tenderness or other early pregnancy symptoms
Signs of Ruptured Ectopic Pregnancy
Concerning Signs (Medical Emergency)
- Severe, sharp abdominal pain that may radiate to shoulder
- Hypotension
- Tachycardia
- Abdominal distention
- Rebound tenderness or peritoneal signs
- Hemodynamic instability
- Hypovolemic shock 3, 2
Physical Examination Findings
Abdominal Examination
- Tenderness in lower quadrants (usually unilateral)
- Rebound tenderness with peritoneal irritation
- Distention with significant hemoperitoneum
Pelvic Examination
- Cervical motion tenderness
- Adnexal tenderness (usually unilateral)
- Adnexal mass (may be palpable in 50% of cases)
- Uterine enlargement (less than expected for dates)
- Malodorous discharge may be present 4
Diagnostic Considerations
Risk Stratification
- High-risk patients present with continued pain, heavy bleeding, hemodynamic instability 5
- Low-risk patients may have minimal symptoms with stable vital signs 5
Ultrasound Findings
- Most common finding: nonspecific heterogeneous adnexal mass 1
- Extrauterine mass with fluid center and hyperechoic periphery ("tubal ring") 1
- Empty uterine cavity with positive pregnancy test
- Free fluid in pelvis (concerning for rupture if moderate/large amount or echogenic) 1
- Visualization of extrauterine gestational sac with yolk sac or embryo (definitive but uncommon finding) 1
Laboratory Findings
- Positive pregnancy test (serum or urine hCG)
- Serial β-hCG levels that do not rise appropriately (normal is 53-66% increase over 48 hours) 5
- Progesterone levels may be lower than in normal intrauterine pregnancy
Atypical Presentations
Non-Tubal Ectopic Locations
- Interstitial/cornual (in uterine cornua)
- Cervical
- Cesarean section scar
- Ovarian (rare)
- Abdominal (rare) 1, 4
Heterotopic Pregnancy
- Simultaneous intrauterine and extrauterine pregnancies
- Rare in spontaneous pregnancies (1 in 30,000)
- More common with assisted reproduction techniques 1
Clinical Pitfalls and Caveats
Do not rely solely on discriminatory β-hCG threshold - Ectopic pregnancy can occur at any β-hCG level 5
Do not exclude ectopic pregnancy based on presence of intrauterine fluid - Early intrauterine fluid collection can be mistaken for gestational sac
Do not delay imaging in symptomatic patients - Ultrasound should be performed regardless of β-hCG level in symptomatic patients 5
Do not miss non-tubal locations - Less common locations like interstitial, cervical, or cesarean scar pregnancies have higher mortality rates
Do not confuse with other conditions - Symptoms may mimic miscarriage, pelvic inflammatory disease, or ovarian cyst torsion 4
Do not discharge without definitive diagnosis - Pregnancy of unknown location requires close follow-up with serial β-hCG and ultrasound 1, 2
Early recognition of signs and symptoms is critical as ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths in the United States 2.