Introduction
An ectopic pregnancy implants outside the uterine cavity. It occurs in about 1–2% of pregnancies, and 95% are in the tube (mostly the ampulla). Rupture with intra-abdominal bleeding is a leading cause of first-trimester maternal death.
Risk factors
- Previous ectopic pregnancy, tubal surgery or sterilisation.
- Pelvic inflammatory disease (chlamydia), endometriosis.
- Pregnancy with an IUD in place (the IUD lowers the overall risk, but a pregnancy that occurs is more often ectopic).
- Assisted reproduction, smoking, age > 35.
Clinical picture
- Classic triad: amenorrhoea (6–8 weeks), abdominal pain, vaginal bleeding, but many cases are vague.
- Shoulder-tip pain, fainting, diarrhoea or painful defecation suggest blood in the peritoneum.
- Examination: adnexal tenderness, cervical motion tenderness; in rupture, peritonism, tachycardia, hypotension, shock.
Diagnosis
A positive test with no pregnancy seen anywhere is a pregnancy of unknown location, followed with serial hCG and ultrasound.
Management
Give anti-D to RhD-negative women treated surgically. Rarer sites (cervical, interstitial, caesarean scar, ovarian, abdominal) need specialist care.
Any woman of reproductive age with abdominal pain or fainting needs a pregnancy test: a ruptured ectopic can kill within hours.