Ectopic Pregnancy: Symptoms and Treatment Options
The primary symptoms of ectopic pregnancy include abdominal pain and vaginal bleeding, with potential for life-threatening rupture requiring immediate surgical intervention, while treatment options include methotrexate therapy for stable patients with small ectopic masses or surgical management via salpingostomy or salpingectomy for unstable patients or those with contraindications to medical therapy. 1
Symptoms of Ectopic Pregnancy
Common Presenting Symptoms
- Vaginal bleeding (occurs in most patients)
- Lower abdominal or pelvic pain (unilateral in many cases)
- Amenorrhea or missed period
- Positive pregnancy test
Warning Signs of Rupture
- Severe, sudden abdominal pain
- Referred shoulder pain (due to diaphragmatic irritation from intraperitoneal blood)
- Dizziness, lightheadedness, or syncope
- Hemodynamic instability (tachycardia, hypotension)
- Increasing free fluid in the pelvis with echoes (representing blood) 2
Diagnostic Approach
Initial Assessment
- Serum β-hCG measurement
- Transvaginal ultrasound to identify:
- Absence of intrauterine pregnancy
- Extraovarian adnexal mass (most commonly in fallopian tube)
- "Tubal ring" sign - extrauterine mass with fluid center and hyperechoic periphery 2
- Free fluid in pelvis (especially if containing echoes)
Definitive Diagnosis
- Visualization of yolk sac or embryo in adnexa is 100% specific but uncommon 2
- Most ectopic pregnancies appear as nonspecific heterogeneous masses outside the ovary 2
- Pregnancy of unknown location (PUL) requires serial β-hCG measurements and ultrasounds for definitive diagnosis 2
Treatment Options
Medical Management with Methotrexate
- Appropriate for hemodynamically stable patients with:
Methotrexate Protocol
- Standard dose: 50 mg/m² intramuscularly
- Single-dose or multiple-dose regimens available (multiple-dose has higher success rate: 92.7% vs 88.1%) 3
- Requires close follow-up with serial β-hCG measurements until levels become undetectable 3
Contraindications to Methotrexate
- Hemodynamic instability
- Known hypersensitivity to methotrexate
- Active liver disease
- Blood dyscrasias
- Immunodeficiency syndromes
- Alcoholism
- Breastfeeding mothers 3
Surgical Management
- Indicated for:
Surgical Options
- Laparoscopic approach preferred when patient is stable
- Salpingostomy (tube-preserving) or salpingectomy (tube removal)
- Laparotomy may be necessary in unstable patients 2
Expectant Management
- Rarely appropriate
- May be considered in highly selected cases with:
- Very low and declining β-hCG levels
- No symptoms
- High compliance with follow-up 1
Post-Treatment Considerations
Follow-up After Medical Treatment
- Weekly β-hCG measurements until undetectable (<2 IU/L)
- Avoid pregnancy for at least 3 months after methotrexate (teratogenic risk)
- Avoid folic acid supplements, NSAIDs, and aspirin during treatment 3
- Anti-D immunoglobulin for Rh-negative women 3
Warning Signs Requiring Immediate Care
- Increasing abdominal pain (may indicate rupture)
- Heavy vaginal bleeding
- Dizziness or fainting
- Fever 3
Treatment Failure Considerations
- Methotrexate treatment failure rates range from 3% to 29% 2
- Risk of tubal rupture after methotrexate: 0.5% to 19% 2
- Risk factors for treatment failure:
Ruptured ectopic pregnancy must always be considered in the differential diagnosis of patients who present with concerning symptoms after methotrexate therapy, as this life-threatening complication can occur even after treatment has begun 2.