Management of ectopic pregnancy

American Family Physician,  April, 1990  by Richard E. Leach,  Steven J. Ory

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The incidence of ectopic pregnancy has quadrupled since 1970, with 78,400 cases in 1985, or one case in 66 pregnancies., During this same period, there was a sevenfold decrease in maternal mortality, with 33 deaths reported to the Centers for Disease Control in 1985. [1] The availability of rapid and sensitive radioimmunoassays for human chorionic gonadotropin (HCG), advances in pelvic ultrasonography and the prevalent use of laparoscopy are thought to contribute to early diagnosis and the decrease in the incidence of tubal rupture and maternal death.

Nevertheless, one study [2] revealed that in over one-half of the instances of maternal death, the patient was seen during the preceding 48 hours by a physician. A high index of suspicion, a careful history and physical examination, and appropriate use of laboratory and ultrasound technologies are thus needed for early diagnosis and intervention, before life-threatening sequelae occur. With early intervention, more conservative treatment may be utilized in the hope of enhancing the patient's future fertility. Despite early diagnosis and regardless of the treatment modality, however, future fertility is uniformly compromised.

Risk Factors

Several risk factors are associated with ectopic pregnancy (Table 1). [3] The presence of an intrauterine device (IUD) at the time of conception raises the risk for ectopic implantation. A history of IUD use, in contrast, has not been found to impart an increased relative risk of ectopic pregnancy.

A history of tubal surgery, including tuboplasty, salpingectomy and tubal ligation, places the patient at risk of ectopic pregnancy. Although it is tempting to attribute the need for tubal surgery to underlying pelvic inflammatory disease, stratified analysis has revealed an independent association between ectopic pregnancy and the surgery itself.

A history of prior ectopic pregnancy increases the recurrence rate to 15 percent. In addition pelvic inflammatory disease has been positively correlated with ectopic pregnancy in several studies in Europe and the United States. [3] This increased relative risk suggests the need for early, aggressive treatment of pelvic inflammatory disease with parenteral antibiotics. Several studies have suggested that the relative risk of ectopic pregnancy is increased in women with infertility. It remains to be determined whether this risk is attributable to preexisting disease, various therapeutic manipulations (such as in vitro fertilization), the use of ovulation-inducing agents (clomiphene [Clomid] and human menopausal gonadotropin [Pergonal]) or advanced age. [3]

Clinical Presentation

The clinical presentation of patients with ectopic pregnancy is varied, ranging from nonspecific abdominal complaints to frank hemodynamic compromise. The spectrum of physical findings represents the manifestations of the natural course of ectopic pregnancy. The majority of ectopic pregnancies are located within the lumen of the fallopian tube (Figure 1) [4]

HISTORY

Abdominal pain, a history of amenorrhea, and vaginal bleeding are the most common symptoms of ectopic pregnancy. In two series, [4,5] abdominal pain was present in 97 percent and 100 percent of the cases (Table 2). Localized pain early in the course is produced by tubal distention. If tubal rupture and hemoperitoneum occur, the resultant generalized pain is typical of that produced by peritoneal irritation.

Other complaints may include nausea, vomiting, tenesmus, syncope and shoulder pain. Shoulder pain is related to diaphragmatic irritation, with pain referred by way of the C4 nerve root. When preceded in onset by generalized abdominal pain, shoulder pain is presumptive evidence of hemoperitoneum. Amenorrhea may not be an associated finding in 25 percent of patients, making the diagnosis of pregnancy less apparent. [5]

Nonmenstrual uterine bleeding near the time of expected menses may be the result of three separate pregnancy-associated events: implantation of the embryo into the decidualized endometrium; early spontaneous abortion of a nonviable embryo, or endometrial sloughing as a result of impaired corpus luteum function, which is often associated with abnormal gestation, either intrauterine or ectopic. Bleeding due to these causes may be misinterpreted as menstruation. Although bleeding due to ectopic pregnancy is not as great as that associated with spontaneous abortion, heavy bleeding should not be viewed as incompatible with ectopic pregnancy.

PHYSICAL EXAMINATION

Orthostatic blood pressure and pulse changes will identify those patients with hypovolemia as a result of hemoperitoneum. Significant orthostatic changes usually do not occur in otherwise healthy women until 10 to 15 percent of the blood volume is lost. Since cardiovascular reserve is generally ample in such patients, signs of hemodynamic instability mandate prompt surgical intervention. Low-grade fever may also be noted and probably represents a nonspecific response to peritoneal inflammation caused by hemoperitoneum. [4]