With later diagnosis, the classic triad is delayed menstruation, pain, and vaginal bleeding or spotting. With tubal rupture, lower abdominal and pelvic pain is usually severe and frequently described as sharp, stabbing, or tearing. Abdominal palpation elicits tenderness. Bimanual pelvic examination, especially cervical motion, causes exquisite pain. The posterior vaginal fornix may bulge from blood in the rectouterine cul-de-sac, or a tender, boggy mass may be felt beside the uterus. The uterus can also be slightly enlarged due to hormonal stimulation. Symptoms of diaphragmatic irritation, characterized by neck or shoulder pain, especially on inspiration, develop in perhaps half of women with sizable hemoperitoneum.
Some degree of vaginal spotting or bleeding is reported by 60 to 80 percent of women with tubal pregnancy. Although profuse vaginal bleeding suggests an incomplete abortion, such bleeding occasionally is seen with tubal gestations. Moreover, tubal pregnancy can lead to signiicant intraabdominal hemorrhage. Responses to moderate bleeding include no change in vital signs, a slight rise in blood pressure, or a vasovagal response with bradycardia and hypotension. Blood pressure will fall and pulse will rise only if bleeding continues and hypovolemia
FIGURE 19-2 This decidual cast was passed by a patient with a tubal ectopic pregnancy. The cast mirrors the shape of the endometrial cavity, and each arrow marks the portion of decidua that lined the cornua.
becomes significant. Vasomotor disturbances develop, ranging from vertigo to syncope.
Even after substantive hemorrhage, hemoglobin or hematocrit readings may at irst show only a slight reduction. Hence, after an acute hemorrhage, a trending decline in hemoglobin or hematocrit levels over several hours is a more valuable index of blood loss than is the initial level. In approximately half of women with a ruptured ectopic pregnancy, varying degrees of leukocytosis up to 30,000/�L may be documented.
Decidua is endometrium that is hormonally prepared for pregnancy, and the degree to which the endometrium is converted with ectopic pregnancy is variable. Thus, in addition to bleeding, women with ectopic tubal pregnancy may pass a decidual cast. his is the entire sloughed endometrium that takes the form of the endometrial cavity (Fig. 19-2). Importantly, decidual sloughing may also occur with uterine abortion. hus, tissue is carefully evaluated visually by the provider and then histologically for evidence of a conceptus. If no clear gestational sac is seen or if no villi are identified histologically within the cast, then the possibility of ectopic pregnancy must still be considered.
he diferential diagnosis for abdominal pain coexistent with pregnancy is extensive. Pain may derive from uterine conditions such as miscarriage, infection, degenerating or enlarging leiomyomas, or round-ligament pain. Adnexal disease may include ectopic pregnancy; hemorrhagic, ruptured, or torsed ovarian masses; salpingitis; or tuboovarian abscess. Last, appendicitis, cystitis, renal stone, and gastroenteritis are more common nongynecological sources of lower abdominal pain in early pregnancy.