O&G · Early pregnancy care
Ectopic pregnancy
Also known as Tubal pregnancy · Extrauterine pregnancy · Ruptured ectopic · Interstitial pregnancy · Cornual pregnancy · Caesarean scar pregnancy · Heterotopic pregnancy
Exam-exhaustive FRANZCOG fellowship reference on ectopic pregnancy — the anatomical classification and risk factors, the transvaginal ultrasound diagnostic ladder, the methotrexate single-dose protocol with its day 4 and day 7 monitoring and failure criteria, salpingotomy versus salpingectomy with the ESEP fertility evidence, the management of each non-tubal ectopic, and anti-D and psychological aftercare. RANZCOG C-Gyn 38 primary, with RCOG Green-top 21, ACOG Practice Bulletin 193 and SOGC Guideline 414 deltas.
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Target exams
Red flags
- Any woman of reproductive age with abdominal pain, syncope or vaginal bleeding has a pregnancy test before anything else
- Pain that exceeds bleeding, lateralised tenderness and cervical excitation — the ectopic signature
- Shoulder-tip pain plus cardiovascular compromise is a ruptured ectopic until proven otherwise; theatre, not a scan
- An empty uterus with a central, single-outlined fluid collection is a pseudosac, not a gestational sac
- An ectopic pregnancy can produce a reassuring hCG rise — the rise does not locate the pregnancy
- Chest pain, mouth ulceration or a dry cough after methotrexate — stop and reassess for toxicity
It is 02:00 and a 29-year-old is on a trolley, pale, with shoulder-tip pain and a systolic of 80. She did not know she was pregnant. This is the presentation that kills young women in early pregnancy, and it still does — ectopic pregnancy remains a leading cause of first-trimester maternal death even in countries with universal scanning. The registrar who wins is the one who reaches for the pregnancy test, then the theatre list, in that order.[3][8]
Overview and definition
An ectopic pregnancy implants anywhere outside the uterine cavity. Around 11 in every 1000 pregnancies are ectopic, and about 95% of those are tubal, with roughly 80% of tubal ectopics in the ampulla. The remaining 5% are the non-tubal ectopics — interstitial, cervical, caesarean scar, ovarian and abdominal — and they are disproportionately dangerous because they are diagnosed later and bleed more.[9][3]
The whole topic turns on one discipline: locate the pregnancy before you act on the hormone. Every modern error in ectopic care — a terminated wanted intrauterine pregnancy, a delayed rupture, a methotrexate given to a viable pregnancy — comes from asking the hCG to answer the question that only the scan can answer.[8][16]
References18ShowHide
- [1]Royal College of Obstetricians and Gynaecologists Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21 BJOG, 2016.PMID 27813249
- [2]American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy Obstet Gynecol, 2018.PMID 29470343
- [3]Barnhart KT Clinical practice. Ectopic pregnancy N Engl J Med, 2009.PMID 19625718
- [4]Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial Lancet, 2014.PMID 24499812
- [5]Lipscomb GH, Bran D, McCord ML, et al. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate Am J Obstet Gynecol, 1998.PMID 9662322
- [6]Lipscomb GH, McCord ML, Stovall TG, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies N Engl J Med, 1999.PMID 10607814
- [7]McCord ML, Muram D, Lipscomb GH, et al. Methotrexate therapy for ectopic pregnancy in adolescents J Pediatr Adolesc Gynecol, 1996.PMID 8795780
- [8]Barnhart KT Early pregnancy failure: beware of the pitfalls of modern management Fertil Steril, 2012.PMID 23084007
- [9]Parker VL, Srinivas M Non-tubal ectopic pregnancy Arch Gynecol Obstet, 2016.PMID 27056054
- [10]Chetty M, Elson J Treating non-tubal ectopic pregnancy Best Pract Res Clin Obstet Gynaecol, 2009.PMID 19230785
- [11]Long Y, Zhu H, Hu Y, et al. Interventions for non-tubal ectopic pregnancy Cochrane Database Syst Rev, 2020.PMID 32609376
- [12]Po L, Thomas J, Mills K, et al. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies J Obstet Gynaecol Can, 2021.PMID 33453378
- [13]Gulino FA, Ettore C, Ettore G A review on management of caesarean scar pregnancy Curr Opin Obstet Gynecol, 2021.PMID 34325464
- [14]Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis Fertil Steril, 1996.PMID 8641479
- [15]Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined Obstet Gynecol, 2004.PMID 15229000
- [16]Bobdiwala S, Kyriacou C, Christodoulou E, et al. Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: a prospective multicenter cohort study Acta Obstet Gynecol Scand, 2022.PMID 34817062
- [17]Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: a multicenter, prospective, cohort study Am J Obstet Gynecol, 2020.PMID 31953115
- [18]Kirk E, Bourne T Diagnosis of ectopic pregnancy with ultrasound Best Pract Res Clin Obstet Gynaecol, 2009.PMID 19356985