What are the symptoms and treatment options for an ectopic pregnancy?

Ectopic Pregnancy: Symptoms and Treatment

Classic Symptom Triad

Any woman of reproductive age presenting with abdominal pain, vaginal bleeding, and amenorrhea in early pregnancy should be evaluated for ectopic pregnancy until proven otherwise. 1, 2

The most common presenting symptoms include:

• Abdominal pain (often unilateral, lower quadrant) - present in the majority of cases and may be ipsilateral to the corpus luteum in 70-80% of cases 1
• Vaginal bleeding - typically lighter than normal menstrual bleeding 2
• Amenorrhea - missed menstrual period, though some patients may report irregular bleeding 3, 2

Additional Clinical Findings

• Unilateral adnexal tenderness on pelvic examination, which correlates with the side of the ectopic pregnancy in 70-80% of cases 1
• Orthostatic symptoms or hemodynamic instability in cases of rupture 4
• Peritoneal signs (rebound tenderness, guarding) indicate likely rupture requiring immediate surgical intervention 4, 2

Diagnostic Approach

Ultrasound Findings (Transvaginal)

Transvaginal ultrasound combined with β-hCG monitoring is the diagnostic standard for suspected ectopic pregnancy. 5, 6

Definitive ultrasound findings include:

• Extrauterine gestational sac with yolk sac or fetal pole - 100% specific for ectopic pregnancy but uncommon 1
• "Tubal ring" - extrauterine mass with fluid center and hyperechoic periphery 1
• Nonspecific heterogeneous adnexal mass - the most common sonographic finding in tubal pregnancy 1
• Free fluid in pelvis with internal echoes (suggesting blood) - concerning for rupture even without visible extraovarian mass 1

β-hCG Correlation

• Absence of intrauterine pregnancy when β-hCG >3,000 mIU/mL should raise strong suspicion for ectopic pregnancy 1
• However, do not use β-hCG value alone to exclude ectopic pregnancy - approximately 22-36% of ectopic pregnancies present with β-hCG levels <1,000 mIU/mL 1, 7, 8
• Serial β-hCG measurements every 48 hours are essential when ultrasound is indeterminate - viable intrauterine pregnancy typically doubles every 48-72 hours 7, 2

Risk Stratification by β-hCG Level

In patients with indeterminate ultrasound:

• β-hCG >2,000 mIU/mL: 57% ectopic pregnancy rate 4
• β-hCG <2,000 mIU/mL: 28% ectopic pregnancy rate 4
• β-hCG >3,000 mIU/mL with no gestational sac: 9% ectopic pregnancy rate 4

Treatment Options

Immediate Surgical Management (Emergency)

Transfer immediately for surgery if any of the following are present: 2, 9

• Hemodynamic instability (hypotension, tachycardia, orthostasis) 2
• Peritoneal signs on examination (rebound, guarding, rigidity) 2
• Ruptured ectopic pregnancy with hemoperitoneum 4, 3

Surgical options include:

• Laparoscopic salpingectomy - removal of affected fallopian tube (preferred for unstable patients or extensive tubal damage) 9
• Laparoscopic salpingostomy - preservation of tube with removal of ectopic pregnancy (for stable patients desiring future fertility) 9
• Laparotomy - for hemodynamically unstable patients or when laparoscopy is not feasible 3, 9

Medical Management with Methotrexate

Methotrexate is appropriate for hemodynamically stable patients meeting specific criteria. 4, 2

Eligibility criteria for methotrexate:

• Hemodynamically stable with no signs of rupture 2, 9
• β-hCG level typically <5,000 mIU/mL (though protocols vary) 2
• No fetal cardiac activity visualized 4
• Ectopic mass <3.5-4 cm on ultrasound 2
• Patient able to comply with close follow-up 4
• No contraindications to methotrexate (renal/hepatic dysfunction, immunodeficiency, blood dyscrasias) 2

Treatment Outcomes and Complications

Methotrexate therapy has a 15-23% treatment failure rate and 0.5-19% rupture rate, requiring close monitoring. 4

Key monitoring requirements:

• Serial β-hCG measurements on days 4 and 7 after methotrexate administration 2
• Immediate evaluation for increasing abdominal pain or hemodynamic instability 4
• Repeat methotrexate dose may be needed if β-hCG fails to decline appropriately 4
• 12% of patients require rehospitalization after methotrexate treatment 4

Higher failure rates occur with:

• Larger ectopic pregnancies on ultrasound 4
• Higher initial β-hCG levels 4
• Visualized fetal cardiac activity 4

Expectant Management

Expectant management is rarely appropriate and only for highly selected cases with declining β-hCG levels and no symptoms. 5, 2

Critical Management Pitfalls

• Never defer ultrasound based solely on "low" β-hCG levels - ectopic pregnancies can rupture at any β-hCG level 1, 7
• Never discharge patients with indeterminate ultrasound without ensuring reliable follow-up - obtain specialty consultation or arrange close outpatient follow-up for ALL patients with pregnancy of unknown location 1, 8
• Never use the traditional discriminatory threshold of 3,000 mIU/mL alone to predict ectopic pregnancy - this has virtually no diagnostic utility (positive likelihood ratio 0.8) 7
• Patients developing increasing pain after methotrexate require immediate evaluation with ultrasound to exclude rupture 4

Follow-Up Protocol for Indeterminate Cases

For stable patients with pregnancy of unknown location:

• Repeat β-hCG in 48 hours to assess for appropriate rise or fall 1, 7
• Repeat transvaginal ultrasound when β-hCG reaches 1,500-3,000 mIU/mL or in 7-10 days 7
• Obtain specialty consultation (OB/GYN) for all indeterminate cases 1, 8
• Ensure patient understands warning signs requiring immediate return: severe abdominal pain, syncope, heavy vaginal bleeding, shoulder pain 2