History and exam
Key diagnostic factors
common
abdominal pain
Common in ectopic pregnancy but also present in other conditions in the differential diagnosis (e.g., miscarriage).
Typically unilateral lower abdominal pain; however, women may present with generalised or upper abdominal pain.
Pain with vomiting may be indicative of tubal rupture.[42]
amenorrhoea
Last menstrual period typically 6-8 weeks before presentation.
vaginal bleeding
Like abdominal pain, also seen in other conditions in the differential diagnosis (e.g., miscarriage, pelvic inflammatory disease and cervicitis).
abdominal tenderness
May also be present in early pregnancy loss; typically lower quadrant with voluntary guarding.
If involuntary guarding, rebound, or other acute abdomen findings present, could be warning sign of rupture.
adnexal tenderness or mass
Presence of adnexal tenderness or mass increases the likelihood of ectopic pregnancy.[45]
blood in vaginal vault
May be present in the absence of rupture.
uncommon
haemodynamic instability, orthostatic hypotension
Bleeding from the implantation site can be haemodynamically significant.
Hypotension and tachycardia are warning signs of possible rupture.
cervical motion tenderness
Often caused by irritation from intraperitoneal bleeding.
Possible warning sign of rupture.
Other diagnostic factors
uncommon
urge to defecate
From pooling of blood in the cul-de-sac.
Warning sign of possible rupture.
referred shoulder pain
Bleeding from the fallopian tube may irritate the diaphragm leading to referred shoulder pain.
Warning sign of possible rupture.
Risk factors
strong
previous ectopic pregnancy
Related to the underlying factor that led to the initial ectopic pregnancy.
Risk increases with the number of previous ectopic pregnancies. Risk of ectopic pregnancy is approximately 10% if the woman has had one previously (OR 3.0; 95% CI 2.1 to 4.4) and 25% with two or more previous ectopic pregnancies (OR 11.17; 95% CI 4.0 to 29.5).[25]
One retrospective review found the rates of recurrence following single-dose methotrexate, salpingectomy, and linear salpingostomy to be 8%, 9.8%, and 15.4% respectively.[26]
previous tubal sterilisation surgery
Believed to be due to possibility of tuboperitoneal fistula formation leading to spermatozoa escape and oocyte fertilisation.
A long-term, multicentre, prospective cohort study showed cumulative rate of 7.3 ectopic pregnancies per 1000 procedures, with bipolar coagulation having the highest incidence at 31.9 per 1000 procedures.[27]
in utero diethylstilbestrol exposure of the mother
Ninefold increase in ectopic pregnancy rate, probably due to altered tubal morphology and possible fimbrial malfunction.[28]
intrauterine device (IUD) use
Copper and levonorgestrel-releasing IUD devices lower the absolute risk of ectopic pregnancy when compared with the non-contraceptive-using general population; however, if a pregnancy occurs with an IUD in situ, there is an increased risk of an ectopic pregnancy.
Progesterone-releasing IUDs show a 50% to 80% higher risk than in the non-contraceptive-using controls, possibly due to action on the endometrium or delayed tubal motility.[29] Odds ratio: 1.1 to 4.5.[2]
previous genital infections
chronic salpingitis
Syndrome manifesting as diverticuli of the fallopian tubes.
Aetiology unknown; theories include congenital or postinfectious.
salpingitis isthmica nodosa
Nodular scarring of fallopian tubes.
Aetiology of this is unknown; possibly postinfectious.
infertility
May reflect the higher incidence of abnormal fallopian tubes.
multiple sexual partners
Increases risk of pelvic inflammatory disease.
Odds ratio: 1.4 to 4.8.[2]
smoking
Odds ratio of 1.9 to 3.5 in women who smoke, dose-dependent.[32]
Probably due to decreased immunity resulting in higher risk of pelvic infection and impaired tubal motility associated with tobacco smoke.
Cigarettes are the tobacco product used most commonly in pregnancy, but use of alternative forms (e.g., e-cigarettes and vaping products) is increasing. There is likely to still be an increased risk of ectopic pregnancy due to exposure to nicotine and/or flavourants and combustion products with these alternatives, although more evidence is required to confirm this.[33]
race/ethnicity
Black women are at increased risk compared with white women.[18]
weak
assisted reproductive technology (ART)
Increased risk of ectopic and heterotopic pregnancy, with tubal factor subfertility as the most commonly associated risk factor.[34][35]
Increased risk of ectopic pregnancy after ART in women with tubal factor infertility compared with other types of infertility.[36]
There is evidence that frozen-thawed embryo transfer is associated with a lower incidence of ectopic pregnancy compared with fresh embryo transfer.[37]
Increased risk of ectopic pregnancy following transfer of multiple embryos.[36]
first sexual encounter <18 years
Age under 18 years at first sexual encounter is associated with higher rates of ectopic pregnancy.[38]
maternal age >35 years
tubal reconstruction surgery
Thought to be a risk factor, but most of the women receiving this treatment would not have conceived spontaneously, and some of the excess ectopic pregnancies observed in this population may have been caused by the underlying tubal damage that required the surgical intervention.
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