Medically Fit For Exams
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Ectopic pregnancy & PUL - Dr Deac Pimp


  • A pregnancy occurring anywhere outside the uterus, most common location is the fallopian tubes (97%)
  • Interstitial = Occurring in the part of the tube that is within the uterine cavity (2-3%)
  • Cornual = Occurring in the rudimentary horn of a bicornuate uterus
  • PUL (pregnancy of unknown location) = positive pregnancy test, but no pregnancy identifiable on ultrasound


Risk factors

  • History of PID
  • Tubal scarring
  • Previous gynaecological surgery
  • Previous ectopic pregnancy
  • IUD in situ
    • Rates are overall LOWER than in those trying to conceive, but in cases when IUD fails, rates of ectopic pregnancies can be as high as 50%
  • Tubal adhesions from endometriosis
  • IVF or history of sub-fertility
  • Failed progesterone-only contraception
  • Age >35
  • Smoking
  • No identified risk factors in 1/3 of ectopics


Differential diagnoses

  • Molar pregnancy
  • Miscarriage
  • Ovarian cyst rupture or torsion
  • Endometriosis
  • Endometrial cancer
  • Fibroid
  • Non-gynaecological:
    • Appendicitis
    • Bowel pathology
    • Pancreatitis



  • 11 per 1,000 pregnancies in UK
  • 0.2% result in maternal death (this is still decreasing)



  • Implantation of pregnancy outside of the uterus
  • Can be a result of scarring or damage to the tubes/uterus
    • Obstruction of passage of ovum/zygote into uterus
    • Abnormal structure


Clinical features

  • Main presentation in bleeding and abdominal/pelvic pain
    • Classic triad: PV bleeding, pelvic pain and amenorrhoea
  • Pain is the most important symptom, and usually occurs before bleeding
    • In miscarriage/threatened miscarriage, bleeding often occurs before pain
  • Can present in atypical fashion, so should be considered a differential in all women of reproductive age with abdominal/pelvic pain and/or PV (per vagina) bleeding
  • Bleeding may have clots/tissue
  • Often preceded by a missed period
  • Dizziness or fainting
  • Breast tenderness
  • Shoulder tip pain
  • Dysuria
  • Rectal pain/difficulty in defecation
  • Diarrhoea and/or vomiting
  • Ruptured ectopic will result in haemorrhage, majority into pelvis rather than PV
    • Tachycardia
    • Hypotension
    • Sweaty, clammy, pale
    • Dizzy, loss of consciousness
    • Delayed capillary refill
    • DIC



  • Pain is caused by the stretching and compression of structures
  • Bleeding can occur before rupture as a result of local damage from implanting pregnancy and accommodation of growing mass
  • Bleeding can occur as a result of rupture, blood loss is rapid – a surgical emergency



  • Vaginal examination
    • Swab for chlamydia, examine for adnexal masses, tenderness and cervical excitation (moving cervix moves uterus in opposite direction)
  • Ultrasound, likely transvaginal (TV)
    • Can only diagnose ectopic if an adnexal mass is visible outside uterine cavity, otherwise is a PUL
    • 78% of ectopics are on the same side as the corpus luteum
  • In acute presentation:
    • FAST scan in ED to detect fluid in the abdomen
    • FBC
    • Group and save
    • Clotting screen
    • Beta HCG
      • If over >1500iu/L, a pregnancy should be visible on TV scan
      • Would expect bhCG to double/rise by 63% every 48 hours in a normally developing pregnancy



  • Acute presentation:
    • Fluid resuscitation
    • Cross match 2-4 units of blood
    • Emergency laparotomy/laparoscopy
  • Stable presentation:
    • Surgical management:
      • Laparoscopic surgery, usually with unilateral salpingectomy, is main method of treatment
      • May perform salipingotomy instead of salpingectomy, but is associated with higher risk of recurrent ectopic pregnancy and higher risk of retained products
      • Check bhCG 7 days post surgery
        • Expect decline of 90%, if not, consider treatment with methotrexate
    • Medical management:
      • Treatment with methotrexate can be considered in some situations eg when surgery is not appropriate
      • Must have no fetal heartbeat
      • TV USS must show unruptured ectopic mass of <35mm, with no haemoperitoneum
      • Generally if bhCG <1500iu/L
      • May be possible if bhCG is between 1500 and 5000iu/L
    • Expectant management:
      • Only considered if stable, bhCG <100iu/L with USS diagnosis
      • Repeat hCG after 48 hours, looking for a drop of 15% after initial 48 hours
      • Weekly hCG until below 20iu/L
  • Anti-D prophylaxis to Rh negative if surgery occurs, not necessary for medical or expectant



  • Maternal death is 0.2%
  • Increased risk of subsequent ectopic, especially if no salpingectomy of 10-20%
  • Risks of surgery
  • >85% are diagnosed before rupture
  • 64-76% chance of a subsequent intrauterine pregnancy
Ectopic pregnancy and PUL.docx
Microsoft Word document [16.4 KB]

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