Ectopic pregnancy

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An ectopic pregnancy presenting as a complex right adnexal mass

An ectopic pregnancy is a pregnancy in which the fetus is in gestation someplace other than the uterus. Often, ectopic pregnancies occur in the fallopian tube (95% of cases), though they can also be present in the ovaries, abdomen, or cervix (1). One in one hundred pregnancies are ectopic, though this figure is increasing.

Ectopic pregnancy can be caused by pelvic inflammatory disease (PID; including puerperal and post abortal sepsis), previous ectopic pregnancy, pelvic surgery (tuboplasty, ovarian cystectomy, tubal ligation), a ruptured appendix, peritonitis, therapeutic abortion (due to increased risk of PID), endometriosis, IUD use (due to increased risk of PID), tubal anomalies, hormonal alteration or it could be idiopathic.

Symptoms

Usually, patients present with the classic triad of sudden onset abdominal pain, amenorrhea symptoms, and an adnexal mass – the largest symptom is pain. Patients may also present with fainting, abnormal genital tract bleeding, tenesmus, rectal pressure, shoulder tip pain, and other symptoms of pregnancy.

Investigation

When an ectopic pregnancy is suspected, a CBC and urinalysis should be ordered, and the patient's blood typed and cross-matched. Serial quantitative βhCG readings should be taken to assess whether the pregnancy is intrauterine. If the reading is more than 6 500, a sac should be visible by ultrasound.

Ultrasound is also used to diagnose by exclusion. If a sac is seen, then the patient has an intrauterine pregnancy. Otherwise, the patient is likely having an ectopic pregnancy.

Grossly, the uterine tube may be enlarged and filled with blood. The products of conception may also be visible, and the wall may be thinned or ruptured. Microscopically, products of conception such as villi, fetal parts, and an implantation site should be visible. An endometrial sample may show gestational changes, but no products of conception.

Management

If the ectopic is very small (<4cm) and the patient is relatively asymptomatic, medical management can be used, such as with the administration of tamoxifen or methotrexate. Microsurgical procedures can also be used to conservatively manage the situation.

If the ectopic pregnancy is large or unstable, the fallopian tubes can be removed, as well as the ovary if it is involved.

Resources

Sonographic Evaluation of Ectopic Pregnancies