SAQ 390 – Obstetrics and Gynaecology – suspected ectopic pregnancy

Obstetrics and Gynaecology – suspected ectopic pregnancy.

a. Differential diagnoses

• Gynaecological: ovarian torsion, mittelschmerz, ruptured ovarian cyst, or pelvic inflammatory disease.
• Renal: pyelonephritis, UTI, or renal colic.
• Gastrointestinal: appendicitis, inflammatory bowel disease, mesenteric adenitis, hernia, constipation, or Meckel diverticulum.
• Musculoskeletal causes.

b. Risk factors

• Assisted fertility treatment.
• Previous ectopic pregnancy.
• Previous PID or tubal infection.
• Previous tubal surgery.
• Endometriosis.
• Atrophic endometrium.
• Abnormal anatomy such as septate uterus, tumours, or pelvic adhesions.
• Prior tubal ligation, current IUD, oral contraceptive pill use despite pregnancy, or increasing maternal age.

c. Vaginal examination utility

• In a stable patient with vaginal bleeding and ultrasound available within 24-48 hours, vaginal examination usually adds little diagnostically.
• Speculum and bimanual examination may help exclude other bleeding causes, such as vaginal laceration, and may identify passage of tissue suggesting miscarriage.
• Clinical findings have limited specificity: many patients with pain, bleeding, and adnexal mass do not have ectopic pregnancy; adnexal tenderness and mass have modest likelihood ratios, while cervical motion tenderness is more supportive.
• Severe ectopic pregnancy may present with shock, sometimes with relative bradycardia.

d. Management options

• Elective surgical management.
• Emergency surgical management.
• Medical management with methotrexate where appropriate.