No specific symptoms or signs are pathognomonic for ectopic pregnancy, and many disorders can present similarly. Normal pregnancy, threatened or incomplete abortion, rupture of an ovarian cyst, ovarian torsion, gastroenteritis, and appendicitis can all be confused with ectopic pregnancy. Since early diagnosis is crucial, a high index of suspicion should be maintained when any pregnant woman in the first trimester presents with bleeding and/or abdominal pain. Fifteen to twenty percent of ectopic gestations will present as surgical emergencies.
The following symptoms may assist in the diagnosis of ectopic pregnancy.
1. Pain - Pelvic or abdominal pain is present in close to 100% of cases. Pain can be unilateral or bilateral, localized or generalized. The presence of subdiaphragmatic or shoulder pain is more variable, depending on the amount of intraabdominal bleeding.
2. Bleeding - Abnormal uterine bleeding, usually spotting, occurs in roughly 75% of cases, and represents decidual sloughing.
3. Amenorrhea - Secondary amenorrhea is variable. Approximately half of women with ectopic pregnancies have some spotting at the time of their expected menses, and thus do not realize they are pregnant.
4. Syncope - Dizziness, lightheadedness, and/or syncope is present in one-third to one-half of cases.
5. Decidual cast - A decidual cast is passed in 5-10% of ectopic pregnancies, and may be mistaken for products of conception.
On examination, the following signs are important in the diagnosis of ectopic gestation.
1. Tenderness - Diffuse or localized abdominal tenderness is present in over 80% of ectopic pregnancies. Adnexal and/or cervical motion tenderness is present in over 75% of cases.
2. Adnexal mass - A unilateral adnexal mass is palpated in one-third to one-half of patients. Occasionally, a cul-de-sac mass is present. However, the patient’s discomfort may preclude an adequate examination.
3. Uterine changes - The uterus may undergo typical changes of pregnancy, including softening and a slight increase in size.
Hematocrit: The hematocrit will vary depending on the patient population and the degree, if any, of intraabdominal bleeding.
White blood count: The white blood count is variable, and it is not uncommon to see a leukocytosis.
Pregnancy tests: The β-hCG is positive in virtually 100% of ectopic pregnancies. However, a positive test only confirms pregnancy and does not indicate whether it is intrauterine or extrauterine. In normal pregnancy, β-hCG should double every 2 days. However, while two-thirds of ectopic pregnancies have abnormal serial titers, the remaining third show a normal progression. Ultrasound is often helpful in differentiating ectopic from intrauterine pregnancy.
Revision date: June 21, 2011
Last revised: by Jorge P. Ribeiro, MD