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Signs ectopic pregnancy ruptured: Ectopic pregnancy – Symptoms and causes

by alexxlab

Ectopic Pregnancy – Rupture – Symptoms – Management

  • 1 Risk Factors
  • 2 Clinical Features
  • 3 Differential Diagnosis
  • 4 Investigations
  • 5 Management
    • 5.1 Medical
    • 5.2 Surgical
    • 5.3 Conservative
  • 6 Complications

An ectopic pregnancy is any pregnancy which is implanted at a site outside of the uterine cavity. In the UK, 1 in 80-90 pregnancies are ectopic. [NHS UK]

The most common sites include the ampulla and isthmus of the fallopian tube. Less commonly, the ovaries, cervix or peritoneal cavity can be involved.

In this article, we shall look at the risk factors, clinical features and management of an ectopic pregnancy.

By BruceBlaus [CC BY-SA 4.0], via Wikimedia Commons

Fig 1 – An ectopic pregnancy is one that is implanted outside the uterine cavity.

Risk Factors

The risk factors for an ectopic pregnancy are shown in Table 1.

Note: The use of contraception actually reduces the rate of pregnancy. However, if there is failure of the contraception types below, the pregnancy is more likely to be ectopic.

Past Medical HistoryContraceptionIatrogenic
Previous ectopic pregnancy

Pelvic inflammatory disease (due to adhesion formation)

Endometriosis (adhesion formation)

Intrauterine device or intrauterine system

Progesterone oral contraceptive or implant (due to fallopian tube ciliary dysmotility)

Tubal ligation or occlusion

Pelvic surgery – especially tubal surgery (reversal of sterilisation)

Assisted reproduction i.e. embryo transfer in IVF

Clinical Features

The leading symptom of ectopic pregnancy is pain. Patients commonly present with lower abdominal/pelvic pain, with or without vaginal bleeding. There also can be a history of amenorrhoea.

Note: Vaginal bleeding in ectopic pregnancy is the result of decidual breakdown in the uterine cavity due to suboptimal β-HCG levels. Bleeding from a ruptured ectopic pregnancy is usually intra-abdominal, not vaginal.

Other symptoms include:

  • Shoulder tip pain – the irritation of the diaphragm by blood in the peritoneal cavity leads to referred shoulder tip pain. This is because the diaphragm and the supraclavicular nerves (which innervate the shoulder tip) share the C3-C5 dermatomes.
  • Vaginal discharge – brown in colour, classically described as being akin to prune juice. This is the result of the decidua breaking down.

On examination, the patient may have localised abdominal tenderness, with vaginal examination revealing cervical excitation and/or adnexal tenderness.

If the ectopic pregnancy has ruptured, the patient may also be haemodynamically unstable (pallor, increased capillary refill time, tachycardia, hypotension), with signs of peritonitis (abdominal rebound tenderness and guarding). Vaginal examination may reveal fullness in the pouch of Douglas.

Differential Diagnosis

An ectopic pregnancy should always be considered in cases of abdominal pain in a woman of reproductive age.

However, its clinical features are largely non-specific, and can be seen in other conditions:

  • Miscarriage
  • Ovarian cyst accident (this refers to cyst haemorrhage, torsion or rupture)
  • Acute pelvic inflammatory disease
  • Urinary tract infection
  • Appendicitis
  • Diverticulitis

By TeachMeSeries Ltd (2023)

Fig 2 – Differential diagnoses for pain in each region of the abdomen.

Investigations

A pregnancy test (urine β-HCG) is the most important initial investigation for an ectopic pregnancy.

If positive, a pelvic USS should be performed – this can determine the presence or absence of an intrauterine (‘normal’) pregnancy. If an intrauterine pregnancy is not seen on transabdominal USS, a transvaginal scan should be offered.

If a pregnancy cannot be identified on ultrasound scan (but β-HCG is positive), this is termed a pregnancy of unknown location. It has three main differential diagnoses; (i) very early intrauterine pregnancy; (ii) miscarriage; and (iii) ectopic pregnancy. In this situation, a serum β-HCG should be taken:

  • If the initial β-HCG level is >1500 iU (discriminatory level), and there is no intrauterine pregnancy on transvaginal ultrasound, then this should be considered an ectopic pregnancy until proven otherwise, and a diagnostic laparoscopy should be offered.
  • If the initial β-HCG level is <1500 iU and the patient is stable, a further blood test can be taken 48 hours later:
    • In a viable pregnancy, HCG level would be expected to double every 48 hours.
    • In a miscarriage, HCG level would be expected to halve every 48 hours
    • Where the increase or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded and the patient should be managed accordingly.

Other investigations should be used as appropriate to rule in/out the other differential diagnoses – e.g. urinalysis for urinary tract infection.

By Häggström, Mikael. “Medical gallery of Mikael Häggström 2014”. Wikiversity Journal of Medicine [CC0]

Fig 3 – Ectopic pregnancy identified by transvaginal ultrasound, in a woman with an intrauterine contraceptive device (IUD).

Management

Any patient with a suspected ectopic pregnancy should be admitted to hospital. If unstable, an A-E approach should be used to resuscitate the patient. This may include the use of blood products if there are signs of haemodynamic instability.

The definitive management of ectopic pregnancy can be medical, surgical, or conservative.

Medical

Medical management of an ectopic pregnancy is with IM methotrexate. It is an anti-folate cytotoxic agent that disrupts the folate dependent cell division of the developing fetus. The pregnancy will then gradually resolve.

The serum β-HCG level is monitored regularly to ensure the level is declining (by >15% in day 4-5). If there isn’t such a decline, a repeat dose is administered.

Medical management is offered to patients who are stable, with well controlled pain and β-HCG levels <1500 iU/ml. The ectopic should be unruptured, and without a visible heartbeat. The patient should have access to 24-hour gynaecology services and be informed of the symptoms of rupture.

  • Advantages: Avoids the complications of surgical management and the patient can be at home after the injection.
  • Disadvantages: Potential side effects of methotrexate – abdominal pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (patients must be advised to use contraception for 3-6 months after methotrexate use). The treatment can fail, which would necessitate surgical intervention.

Surgical

Surgical management involves the surgical removal of the ectopic pregnancy.

In cases of tubal ectopics (most common), a laparoscopic salpingectomy is usually performed – removing the ectopic and the tube that it is implanted in.

However, if there is damage to the contralateral tube from infection, disease or surgery, a salpingotomy (a cut in the fallopian tube) can be performed to remove the ectopic and salvage the tube to preserve future fertility.

Note: In a salpingotomy, HCG follow up is required until the level reaches <5iU (negative), to ensure there is no residual trophoblast. The risk of recurrent ectopic pregnancy in the salvaged tube will be increased.

Surgical management is typically offered to patients with severe pain, serum β-HCG >5000 mIU/ml, adnexal mass >34 mm and/or fetal heartbeat visible on scan.

  • Advantages: Reassurance about when the definitive treatment can be provided, high success rate.
  • Disadvantages: General anaesthetic risk, risk of damage to neighbouring structures like the bladder, bowel, ureters, DVT/PE, haemorrhage, infection. With salpingotomy, there is also a risk of treatment failure – as some of the pregnancy may remain within the tube.

All rhesus negative women who receive surgical management of an ectopic pregnancy should be offered Anti-D prophylaxis.

By Mikael Häggström [CC BY-SA 3.0], via Wikimedia Commons

Fig 4 – Laparoscopic view of ectopic pregnancy within the left fallopian tube (red arrows). Uterus marked by blue arrows.

Conservative

Conservative management involves watchful waiting of the stable patient, while allowing the ectopic to resolve naturally. This is suitable in a small number of selected patients only, and is not the first line management. This approach needs to be discussed at senior level.

The serum B-hCG should be monitored every 48 hrs to ensure it is falling by equal to or greater 50% of the level until it falls to approximately <5mIU/ml.

This method is offered for patients in whom a rupture is unlikely; these are stable patients, with well controlled pain, with a low baseline β-HCG, small unruptured ectopic on USS.

The patient should have access to 24-hour gynaecology services and informed of the symptoms of rupture.

  • Advantages: Avoid the risks of medical and surgical management, can be done at home.
  • Disadvantages: Failure or complications necessitating medical or surgical management (25% of patients), rupture of ectopic.

Complications

Complications of individual treatments are detailed above.

An untreated ectopic pregnancy can lead to fallopian tube rupture. The resulting blood loss can cause hypovolaemic shock, resulting in organ failure and death.

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Ectopic pregnancy – Symptoms – NHS

Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of pregnancy.

Some women don’t have any symptoms at first. They may not find out they have an ectopic pregnancy until an early scan shows the problem or they develop more serious symptoms later on.

Main symptoms

You may have an ectopic pregnancy if you miss a period, have a positive pregnancy test, and have other signs of pregnancy.

Contact your GP or call NHS 111 if you have a combination of any of these symptoms and you think you might be pregnant – even if you haven’t had a positive pregnancy test.

Vaginal bleeding

Vaginal bleeding tends to be a bit different to your regular period. It often starts and stops, and may be watery and dark brown in colour.

Some women mistake this bleeding for a regular period and don’t realise they’re pregnant.

Vaginal bleeding during pregnancy is relatively common and isn’t necessarily a sign of a serious problem, but you should seek medical advice if you experience it.

Tummy pain

You may experience tummy pain, typically low down on one side. It can develop suddenly or gradually, and may be persistent or come and go.

Tummy pain can have lots of causes, including stomach bugs and trapped wind, so it doesn’t necessarily mean you have an ectopic pregnancy.

But you should get medical advice if you have it and think you might be pregnant.

Shoulder tip pain

Shoulder tip pain is an unusual pain felt where your shoulder ends and your arm begins.

It’s not known exactly why it occurs, but it can be a sign of an ectopic pregnancy causing some internal bleeding, so you should get medical advice right away if you experience it.

Discomfort when going to the toilet

You may experience pain when going for a pee or poo. You may also have diarrhoea.

Some changes to your normal bladder and bowel patterns are normal during pregnancy, and these symptoms can be caused by urinary tract infections and stomach bugs.

But it’s still a good idea to seek medical advice if you experience these symptoms and think you might be pregnant.

Symptoms of a rupture

In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture.

Ruptures are very serious, and surgery to repair the fallopian tube needs to be carried out as soon as possible.

Signs of a rupture include a combination of:

  • a sharp, sudden and intense pain in your tummy
  • feeling very dizzy or fainting
  • feeling sick

Call 999 for an ambulance or go to your nearest accident and emergency (A&E) department immediately if you experience these symptoms.

Page last reviewed: 23 August 2022
Next review due: 23 August 2025

Ectopic pregnancy – terms, causes, symptoms, signs, diagnosis, treatment (surgery, removal)

Causes

Signs

Diagnosis

Treatment

What to do

Ectopic pregnancy is one of the most dangerous pathological conditions in which the fetus develops outside the uterine cavity. The place of its implantation can be the fallopian (uterine) tubes, as well as other organs of the abdominal cavity and small pelvis.

Termination of an ectopic pregnancy is accompanied by intra-abdominal bleeding and severe complications requiring surgical intervention.

In the female body, normal gestation is possible only in the uterus, but in practice, the location of the embryo, in addition to the uterus, may vary.

There are several types of ectopic pregnancy: tubal, ovarian, abdominal, cervical and with a location in the rudimentary horn of the uterus.

The sites listed are unfavorable for gestation, so an ectopic pregnancy is terminated at 4 to 8 weeks to prevent serious complications.

Attached in an atypical place, the vessels of the fetal egg grow into the surrounding tissues. Other organs, besides the uterus, are not able to stretch and form blood vessels for the placenta. As a result, damage to surrounding tissues occurs, exfoliation of the fetal egg, as a result, severe bleeding occurs that threatens the life of the patient.

The appearance of a tubal form of pathology is associated with the presence of obstacles in the movement of a fertilized egg. If the fertilized egg does not reach the uterine cavity, then it is implanted in the fallopian tube. Ectopic fetal development occurs in approximately 2% of cases among all types of pregnancy, of which 9 fall on the tubal form.8%. Fetal implantation in other parts of the uterus and appendages, as well as in the abdominal cavity, is much less common.

The release of a fertilized egg into the abdominal cavity with further implantation to the omentum, peritoneum or intestine leads to the development of abdominal pregnancy. One of the causes of this pathology may be in vitro fertilization.

In cervical pregnancy, the egg is implanted in the columnar epithelium of the cervical canal. As a result of deep penetration of the embryonic villi into the muscular layer of the cervix, the pregnancy ends in very heavy bleeding.

Causes of pathology

The development of pregnancy outside the uterine cavity occurs as a result of failures of natural processes that prevent the penetration of a fertilized egg into it. The most common causes of ectopic pregnancy include:

  • previously transferred infectious lesions of the appendages caused by pathogenic microflora;
  • the presence of adhesions in the fallopian tubes;
  • defects in the structure of the genital organs;
  • installed IUD in the uterus;
  • infantilism;
  • the presence of a tumor in the appendages or uterus;
  • use of assisted reproduction methods;
  • use of hormonal contraceptives;
  • the presence of an inflammatory focus in the pelvic cavity;
  • previously transferred surgical interventions on the appendages;
  • stimulation of the ovulation process;
  • history of abortion;
  • endometriosis.

Features

It is not possible to determine the pathology at home. In this regard, timely registration can play a decisive role in the correct diagnosis.

At an early stage of development, an ectopic pregnancy has no distinguishing features. As a rule, it is characterized by:

  • absence of menstruation;
  • breast engorgement;
  • manifestations or absence of toxicosis;
  • a positive pregnancy test, although in the presence of ectopic pathology it is not pronounced;
  • painful sensations in the lower abdomen with irradiation to the rectal area, as well as “spotting” discharge from the vagina.

Clinical manifestations of fetal development in the fallopian tube

An ectopic pregnancy can have a progressive form, in which case the growing fetal egg penetrates the muscular layer of the fallopian tube, leading to its gradual destruction. The patient has all the symptoms of pregnancy, but there are small bleeding from the genitals.

Also ectopic pregnancy can be terminated:

  • as a tubal abortion. In this case, there is a partial or complete detachment of the membranes of the embryo from the wall of the tube and its entry into the abdominal cavity. Symptoms of manifestations depend on the severity of bleeding. Characterized by the presence of vaginal discharge in the form of blood clots. A pronounced soreness in the lower abdomen joins. Bimanual examination reveals an increase in the size of the uterus and appendages. Palpation of the posterior fornix of the vagina is very painful;
  • is like a ruptured fallopian tube. May occur after the 6th week of pregnancy. This condition is life threatening due to internal bleeding. Patients complain of very severe pain in the lower abdomen on both sides. There is a protrusion of the posterior fornix of the vagina and a “floating” uterus during a bimanual examination.

How to detect an ectopic pregnancy

In the initial period, it is difficult to diagnose pathology. Symptoms indicate, as a rule, the presence of pregnancy, but there are no signs typical for the pathology.

Diagnosis is carried out by examining a woman in a gynecological chair, as well as using additional research methods:

  • blood test for B-hCG, which in case of ectopic pregnancy shows a shorter period than it actually is;
  • Ultrasound, which will give more complete information about the development of the fetal egg and its location.

Interrupted tubal pregnancy is accompanied by intra-abdominal bleeding. Typical symptoms of a pipe rupture will be:

  • acute pain in the lower abdomen radiating to the anus, lumbar region, legs;
  • secretion of blood from the genital tract;
  • rapid, weak pulse;
  • sudden drop in blood pressure;
  • loss of consciousness.

Clinical manifestations of an interrupted tubal pregnancy should be differentiated from appendicitis and ovarian apoplexy. When the embryo is located in the cervical region, pregnancy should be distinguished from incomplete abortion and tumors.

An ectopic pregnancy can be confirmed or denied after ultrasound diagnostics and a blood test for B-hCG.

Treatment

Treatment of ectopic pregnancy is carried out only by surgery. All the efforts of doctors are aimed at maintaining the integrity and function of the fallopian tube, into which the implantation of the fetal egg has occurred. With timely detection of pathology and a small blood loss, a laparoscopic operation is performed.

When localizing the embryo in the tube, the following types of surgical intervention are used:

  • tubotomy (removal of the fetal egg while preserving the tube). In the case of choosing this method, the possibility of recurrence of the pathology is taken into account;
  • tubectomy (excision of the tube) – performed in the presence of severe damage.

The choice of methodology is influenced by the following factors:

  • whether the woman plans to have a child in the future;
  • repeated ectopic pregnancy will require removal of the tube;
  • whether there is an adhesive process in the small pelvis;
  • change in the structure of the wall of the fallopian tube.

If the blood loss is large, then in order to save a life during an ectopic pregnancy, it is necessary to perform an abdominal operation, in which the fetal egg and tube are removed. Plasma transfusion may be required to restore blood loss. It is important that the remaining second pipe fully retains its function.

How to deal with an ectopic pregnancy

To avoid serious complications that can occur during a pathological pregnancy, a timely visit to an obstetrician-gynecologist will help. Attempts to save the fetus can lead to sad consequences: as a result of a ruptured tube, blood flows into the abdominal cavity, which leads to fatal hemorrhagic shock.

When a patient is diagnosed with an ectopic pregnancy, urgent hospitalization is required to terminate the pregnancy.

The author of the article:

Shklyar Alexey Alekseevich

obstetrician-gynecologist, surgeon, KMN, head of the direction “Obstetrics and Gynecology”

work experience 10 years

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I turned to Shklyar Aleksey Alekseevich I want to express my deepest gratitude to the entire staff of the operating unit Aleksey Alekseevich Shklyar. You are all doctors with a capital letter. I never tire of thanking God for bringing me to you. I came to you on the recommendation of Sorvacheva M.V. We got in touch with the doctor by phone and appointed the day of the operation. For the first time, I was pleasantly surprised how Alexey Alekseevich told me everything in detail and reassured me. A couple of weeks later, I arrived at the clinic at 10.00 with a complete list of tests, and already at 11 I was lying on the operating table, to be honest, I didn’t even have time to get scared) Then the anesthetist magician came and I fell asleep sweetly. I woke up already in bed, nothing hurt, there were no side effects, just a normal morning awakening. I would never have believed that this was even possible, I am very grateful for a wonderful dream. Before that, I had more than one general anesthesia in state hospitals, and now I understand for sure that they apparently wanted to kill me there, but it didn’t work out. For the next two hours, until it was impossible to get up, wonderful nurses came to me asking how I felt and if I needed something, they put droppers, and I lay and did not believe that everything terrible was over)) 2 hours after the operation, I was already getting up and drank delicious broth and tea. The rest of the time before sleep, I walked around the ward, I didn’t feel any pain at all, a little weakness and nothing more. The next morning I was fed deliciously and discharged home. After being discharged, Aleksey Alekseevich is constantly in touch, he worries about my well-being more than even my relatives. I needed further treatment, he even helps me with this by calling the best doctors and clinics, supporting me. And now I know for sure that I am in the most reliable hands. Thank you very much again. Prosperity to your clinic and low bow to all your doctors. You are the best!!!

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15.05.2021 15:21:57

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On May 7, 2021, I did a minor gynecological operation in SOD, and I would like to express my gratitude to the attending physician, to the head of the gynecological department Shklyar Aleksey Alekseevich, – for high professionalism, and exceptionally friendly attitude, understandable recommendations. The doctor communicates very correctly, clearly and with explanations.
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