🔑 Key Learning

  • Implantation of a fertilised ovum outside the uterine cavity, most commonly within the fallopian tube.
  • Suspect in all women with abdominal pain, PV bleeding - check pregnancy test
  • Diagnosis is primarily by transvaginal ultrasound and beta-hCG levels.
  • Management options: expectant, medical (methotrexate), or surgical (laparoscopic salpingectomy/salpingotomy).

🧬 Pathophysiology

  • Fertilised ovum implants outside of the uterine cavity.
  • Most common site: fallopian tube.
  • Risk of tubal rupture and intra-abdominal bleeding if untreated.

👀 Clinical Features

Symptoms (typically occur 6–8 weeks after the last menstrual period):

  • Lower abdominal pain
  • PV bleeding
  • Syncope/dizziness
  • Amenorrhoea

Examination findings:

  • Abdominal tenderness ± signs of peritonism (guarding, rebound tenderness)
  • Pelvic tenderness
  • Cervical motion tenderness
  • Abdominal distension
  • Signs of haemodynamic compromise (tachycardia, hypotension, orthostatic hypotension, shock)
  • Referred shoulder tip pain (due to diaphragmatic irritation from intra-abdominal bleeding)

🧪 Investigations

  • Transvaginal ultrasound — first-line diagnostic investigation.
  • Serum beta-hCG — to guide management decisions.

💊 Management

Management options include expectant management, medical treatment, or surgical intervention. The choice depends on haemodynamic stability, ultrasound findings, hCG levels, symptoms, and patient preference.

🧹 Expectant Management

  • Rarely used.
  • Criteria:
    • Clinically stable
    • Pain free
    • Decreasing serum hCG, which were initially < 1500 IU/L
    • Able to attend for close follow-up

💊 Medical Management

  • Criteria:
    • No significant pain
    • Clinically stable (no haemodynamic compromise)
    • Unruptured ectopic pregnancy
    • Adnexal mass < 35mm
    • No visible fetal heartbeat
    • Serum hCG < 1500 IU/L
    • Able to attend follow-up
  • Treatment:
    • 1st Line: Single-dose methotrexate
    • Important advice: Avoid pregnancy for 3 months after treatment due to teratogenicity.

🔪 Surgical Management

  • Indications:
    • Unable to return for follow-up
    • Significant pain
    • Adnexal mass > 35mm
    • Visible fetal heartbeat
    • Serum hCG > 5000 IU/L
    • Haemodynamic instability
  • Options:
    • Salpingectomy (preferred if the contralateral tube is healthy)
    • Salpingotomy (consider if there is a risk to future fertility e.g., previous ectopic, PID, abdominal surgery)
  • Important:
    • All Rhesus-negative women undergoing surgical treatment must receive anti-D immunoglobulin.

📝 Exam Clues & Clinchers

  • Pain + PV bleeding + positive pregnancy test = high suspicion.
  • Shoulder tip pain suggests diaphragmatic irritation (ruptured ectopic).
  • Stable, small ectopic (<35mm) + low hCG (<1500) → consider methotrexate.
  • Significant pain, foetal heartbeat or hCG > 5000 → laparoscopic surgical management.

🔗 Useful Links and References