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Obstetrics

Ectopic Pregnancy

A pregnancy implanted outside the uterine cavity, most commonly in the fallopian tube. A life-threatening emergency if it ruptures, causing intra-abdominal haemorrhage.

Also known as: Tubal Pregnancy

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Referral and warning signs

When to refer

URGENT REFERRAL TO HOSPITAL (H/RR) for ALL suspected ectopic pregnancy cases. Immediate emergency transfer if rupture/shock suspected.

Red flags

  • Signs of shock
  • Sudden severe abdominal pain
  • Shoulder tip pain
  • Signs of peritonism
  • Positive pregnancy test + empty uterus on ultrasound

Signs and symptoms

  • Classic Triad: Amenorrhoea, Vaginal bleeding (slight, dark), Lower abdominal pain (unilateral).
  • Shoulder tip pain (referred).
  • Rupture symptoms: Sudden severe abdominal pain, Dizziness, fainting, collapse, Shock (pallor, tachycardia, hypotension).
  • Exam: Adnexal tenderness, Cervical motion tenderness ('chandelier sign'), +/- Adnexal mass, Abdominal tenderness/guarding (rupture).

Risk factors

  • Previous ectopic pregnancy.
  • History of PID / Salpingitis.
  • Previous tubal surgery.
  • Infertility / ART.
  • IUD use (lower overall risk, higher relative risk if preg occurs).
  • Progestin-only contraceptives.
  • Smoking.
  • Increasing maternal age.

Diagnosis

Clinical assessment

High index of suspicion in woman of reproductive age with abdo pain +/- bleeding +/- amenorrhoea. Assess haemodynamic stability. Differentiate from PID, appendicitis, ovarian cyst accident, miscarriage.

Investigations

  • Urine or Serum beta-hCG Pregnancy Test: Essential. Confirms pregnancy.
  • Transvaginal Ultrasound Scan (TVS): Key. Look for IUP vs empty uterus vs adnexal mass vs free fluid. Empty uterus + hCG >1500-2000 highly suggestive.
  • Quantitative Serum beta-hCG: Serial levels help (slow rise/plateau).
  • FBC (anaemia).
  • Blood Group & Cross-match.
  • Laparoscopy: Gold standard if diagnosis unclear or unstable.

Diagnostic criteria

Visualization on ultrasound/laparoscopy OR Clinical picture + Empty uterus on TVS + Positive hCG > discriminatory zone.

Management

Non-pharmacological management

  • Ruptured Ectopic (Unstable): EMERGENCY. ABC resuscitation. 2 large IV lines. Rapid fluids (caution pre-op). Urgent blood transfusion. Immediate Surgery (Laparotomy usually).
  • Unruptured Ectopic (Stable): Surgical Management (Laparoscopy preferred - Salpingectomy or Salpingostomy) OR Medical Management (Methotrexate IM - select cases, specialist Rx) OR Expectant (Rare - select cases, specialist Rx).
  • Anti-D Immunoglobulin for Rh-negative women.

Pharmacological treatment

  • IV Fluids (NS, RL).
  • Blood products.
  • Analgesia (Opioids).
  • Methotrexate (medical management).
  • Anti-D Immunoglobulin.

Monitoring

Monitor vitals (ruptured/suspected). Post-op monitoring. Serial hCG (medical/salpingostomy).

Complications

  • Tubal rupture.
  • Life-threatening haemorrhage, Shock.
  • Death.
  • Infertility.
  • Recurrent ectopic.
  • Complications of surgery/methotrexate.

Prevention

  • Prevent/treat STIs/PID.
  • Smoking cessation.
  • Awareness of risks.
  • Early diagnosis/ultrasound in high-risk.

Patient education

  • Explanation of condition and seriousness.
  • Treatment options.
  • Need for urgent action.
  • Symptoms of rupture.
  • Follow-up needs.
  • Future fertility implications.
  • Contraception.
  • Emotional support.

Uganda-specific notes

Significant cause of maternal mortality. High index of suspicion needed. Ultrasound/timely surgery access crucial but limited. Laparotomy common. Medical Rx rarely feasible.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.3.3

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