Now, what are patients gonna present with?
What are the things they’re gonna come in with?
So first of all, they may have missed a menstrual period.
They may have missed their cycle or their cycle may have been irregular
in the last month, it may have lasted only for a day
whereas normally it lasts for four, and for some patients,
this may be very obvious.
They maybe the patient that has the app on their smartphone
and they take... you know, they watch it very, very closely.
For other patients, it maybe a little less obvious.
Maybe they have irregular menses.
Maybe they just don’t pay attention quite as much.
Patients may present also with abdominal pain.
The abdominal pain may be peritoneal or more severe
and someone with a ruptured ectopic pregnancy.
So if a patient has a pregnancy that was in the tube or in the cornua,
or another location that ruptured, that’s gonna cause severe pain.
That’s gonna cause peritoneal symptoms
because the peritoneal cavity is full of blood.
Rupture with a lot of blood in the abdominal cavity
may also radiate to the shoulder.
So radiation of pain to the shoulder
can indicate a ruptured ectopic pregnancy.
Now, early on in an ectopic pregnancy before the rupture,
the patient may just have pain localized,
one in adnexa or lower portion in the abdomen or the other,
so either the right or the left adnexa,
or just in the lower abdomen in general.
What we’re talking about here with these words,
the peritoneal pain, the severe pain,
is that patient who has a ruptured ectopic pregnancy.
Patients may also experience vaginal bleeding.
The vaginal bleeding is generally not severe,
so usually, it’s a small amount of vaginal bleeding.
That can help distinguish it from a miscarriage.
Patients who are having a miscarriage
can have a very large amount of vaginal bleeding,
so this may help differentiate it a little bit
when you’re thinking about the differential diagnosis.
What will you see on physical examination?
On physical examination for patients
who have a ruptured ectopic pregnancy,
patients may have tachycardia,
so an elevated heart rate and low blood pressure.
For patients who are pregnant who come in tachycardic
with hypotension, the patient may have syncopized
or passed out at home, that is a ruptured ectopic pregnancy
for that patient until proven otherwise.
For that patient,
you need to make sure you get things moving for them quickly.
You might wanna do a bedside ultrasound to evaluate.
Involve the OBGYN team.
Tachycardia and hypotension plus a positive pregnancy test
should make you very concerned.
On abdominal exam, the patient may have tenderness of the abdomen.
It might be diffused depending on if the pregnancy is ruptured or not,
or it might be more localized to the lower abdomen.
And then, you’ll wanna perform a pelvic exam.
On the pelvic exam, the patient may have cervical motion tenderness.
When you move their cervix, it may cause them discomfort.
You might be able to feel an adnexal mass so either on the right
or the left when you’re doing your bimanual exam, you may feel a mass.
And you may also see vaginal bleeding which is generally relatively light.
It’s important to remember that the history and physical exam
for ectopic pregnancy are nonspecific.
You really need to maintain a high level of suspicion for this diagnosis
in patients with lower abdominal pain
and vaginal bleeding in early pregnancy.
I would say this is your rule out diagnosis when patients come in
with bleeding and pain in early pregnancy.
I even go so far as to say that I have a few rules in emergency medicine.
One of them is that I get an ultrasound for all of these patients
to evaluate for ectopic pregnancy
because this can potentially be a life threatening diagnosis.
An ultrasound is generally easy and safe to obtain.
Please remember, it’s always important to start with a comprehensive
abdominal and pelvic examination to test for other diseases.
With this examination you can try and rule out diagnosis such as
appendicitis, ovarian cysts, gynaecological tumors and molar pregnancies.
A speculum examination to rule out any local causes of bleeding is needed.