Diagnosis The diagnosis of ectopic pregnancy is complicated by the wide spectrum of clinical presentations, from asymptomatic cases to acute abdomen and hemodynamic shock. The diagnosis and management of a ruptured ectopic pregnancy is straightforward; the primary goal is achieving hemostasis. If an ectopic pregnancy can be identified before rupture or irreparable tubal damage occurs, consideration may be given to optimizing future fertility. With patients presenting earlier in the disease process, the number of those without symptoms or with minimal symptoms increased. There must be a high degree of suspicion of ectopic pregnancy, especially in areas of high prevalence. History and physical examination identify patients at risk, improving the probability of detection of ectopic pregnancy before rupture occurs.
History Patients who have an ectopic pregnancy have an abnormal menstrual pattern or the perception of a spontaneous pregnancy loss. Pertinent points in the history include the menstrual history, previous pregnancy, infertility history, current contraceptive status, risk factor assessment, and current symptoms.
The classic symptom triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding. This symptom group is present in about 50% of patients and is typical in patients with a ruptured ectopic pregnancy. Abdominal pain is the most common presenting symptom, but the severity and nature of the pain vary widely. There is no pathognomonic pain that is diagnostic of ectopic pregnancy. Pain may be unilateral or bilateral and may occur in the upper or lower abdomen. The pain may be dull, sharp, or crampy and either continuous or intermittent. With rupture, the patient may experience transient relief of the pain, as stretching of the tubal serosa ceases. Shoulder and back pain, thought to result from hemoperitoneal irritation of the diaphragm, may indicate intra-abdominal hemorrhage.
Physical Examination The physical examination should include measurements of vital signs and examination of the abdomen and pelvis. Frequently, the findings before rupture and hemorrhage are nonspecific, and vital signs are normal. The abdomen may be nontender or mildly tender, with or without rebound. The uterus may be slightly enlarged, with findings similar to a normal pregnancy (103,104). Cervical motion tenderness may or may not be present. An adnexal mass may be palpable in up to 50% of cases, but the mass varies markedly in size, consistency, and tenderness. A palpable mass may be the corpus luteum and not the ectopic pregnancy. With rupture and intra-abdominal hemorrhage, the patient develops tachycardia followed by hypotension. Bowel sounds are decreased or absent. The abdomen is distended, with marked tenderness and rebound tenderness. Cervical motion tenderness is present. Frequently, the findings of the pelvic examination are inadequate because of pain and guarding.
History and physical examination may or may not provide useful diagnostic information. The accuracy of the initial clinical evaluation is less than 50% (105). Additional tests are frequently required to differentiate early viable intrauterine pregnancy or suspected ectopic or abnormal intrauterine pregnancy.
Laboratory Assessment Quantitative β-human chorionic gonadotropin (β-hCG) measurements are the diagnostic cornerstone for ectopic pregnancy. The hCG enzyme immunoassay, with a sensitivity of 25 mIU/mL, is an accurate screening test for detection of ectopic pregnancy. The assay is positive in virtually all documented ectopic pregnancies.