Ectopic Pregnancy – Presentation, Diagnosis and Treatment

An ectopic pregnancy is a serious medical condition that takes place when a fertilised egg implants outside the uterine cavity. The most common site for ectopic pregnancies is within the fallopian tubes. In the UK, this condition affects roughly 11 per 1,000 pregnancies.

Current guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG) stresses the importance of a rapid diagnosis and treatment plan to protect the health of the woman and her future fertility.

In this article, we will discuss the details of ectopic pregnancies, including their signs and symptoms, diagnosis plan, and treatment plan.

What are the signs and symptoms of ectopic pregnancy?

The symptoms of ectopic pregnancy start between 6 and 10 weeks of gestation. Here is the classic clinical presentation of ectopic pregnancy:

• One-sided lower abdominal or pelvic pain.
• Abnormal vaginal bleeding or spotting.
• Dizziness or shoulder-tip pain (this occurs because the muscles of breathing get irritated).
• In severe cases, syncope, pallor, and shock.

Keep in mind that the absence of these symptoms does not necessarily mean that ectopic pregnancy is not possible.

Red-flag symptoms and immediate actions:

Red-flag symptoms and immediate actions:

How early can an ectopic pregnancy be detected?

Biochemically, serum β-hCG becomes detectable 8-10 days after ovulation in viable intrauterine pregnancies. What’s more, serial measurements every 48 hours help us interpret early the health of the pregnancy (rise, plateau, or fall). Ectopic pregnancies show slower-than-expected rises, but patterns still overlap with failing intrauterine pregnancies. Therefore, hCG alone cannot confirm the location.

Transvaginal ultrasound (TVUS) can visualise an intrauterine gestational sac around five weeks’ gestation. In the past, clinicians used a discriminatory zone of serum β-hCG (1,500-2,000 IU/L). Above this range, an intrauterine sac should be visible by ultrasound. However, studies show this threshold is imperfect. In fact, a proportion of ectopic pregnancies never go above 1,500 IU/L.

With all of that said, it’s not ideal to rely on β-hCG levels alone. The best way to diagnose this condition is to combine data from the patient’s history, clinical examination, and ultrasound findings.

Diagnosing an ectopic pregnancy

The diagnostic goal is to localise the pregnancy safely and avoid inadvertent interruption of a potentially healthy intrauterine pregnancy.

In stable patients, the doctor may follow these steps to diagnose ectopic pregnancy:

History and examination

Your doctor will ask you questions about the pain characteristics, bleeding, risk factors (e.g., previous ectopic pregnancy, tubal surgery, pelvic inflammatory disease, assisted reproduction), and whether the patient is stable.

Transvaginal ultrasound

After the history taking and examination, your doctor will perform a transvaginal ultrasound. The goal is to locate any masses (the sac of your embryo) in areas outside of the uterus (e.g., interstitial, cervical, caesarean scar).

β-hCG at presentation and after 48 hours

As we mentioned above, the rising pattern of β-hCG gives us valuable insights into the development of the pregnancy. In ectopic pregnancy, β-hCG tends to rise slowly and doesn’t double every 48 hours.

Pregnancy of unknown location (PUL)

In some cases, your doctor cannot see an intrauterine or ectopic pregnancy. As a result, they will treat it as a pregnancy of unknown location and schedule repeat ultrasounds and β-hCG.

Investigations and what their results suggest:

Treatment options

Management depends on whether the patient is stable or not, 6-week ultrasound findings, Blood tests to check hormone levels and trend, and patient preferences.

Medical management

This is indicated for some patients who don’t have a heartbeat of the foetus. Studies suggest that two doses of methotrexate can improve treatment success and shorten the time of recovery.

Surgical management

Surgery is recommended for unstable patients, those with suspected rupture of the uterus, contraindications to methotrexate, or when the patient chooses that.

Doctors usually treat an ectopic pregnancy with a keyhole operation that removes the affected fallopian tube. This works well, and recovery is quick. The preservation of the damaged tube rarely improves future natural pregnancy and can add risk. Many people still conceive with one healthy tube. Your doctor will recommend the safest option for your health now and your family’s plans.

Special sites and complexities

Not all ectopic pregnancies develop in the fallopian tubes. These can also occur in the intestines, cervix, ovaries, abdomen, and even the C-section scar. In these situations, a subspecialist is needed to provide input and plan a personalised management plan.

Future fertility and recurrence

Most people will still have good prospects for future intrauterine pregnancy after appropriate treatment. After a salpingectomy (i.e., the removal of the fallopian tube) where the other fallopian tube is normal, spontaneous fertility remains favourable.

Salpingotomy (i.e., cut the tube to remove the pregnancy but leave the tube in place). This procedure rarely improves natural conception rates and may increase the risk of other complications. The recurrence risk after one ectopic pregnancy is around 10%-15% in studies. That’s why early transvaginal scanning in the next pregnancy is advised.

FAQ’s

Ectopic pregnancy is a clinical emergency that could be life-threatening. That’s why expert ultrasound and serial β-hCG are absolutely indispensable. The management plan should be customised to the patient’s needs and status.