An ectopic pregnancy may have an acute or chronic presentation.
Common initial presentations include (although <50% of women with ectopic pregnancy presents with these typical symptoms) (1):
- amenorrhoea or a history of an abnormal last menstrual period - in 75-90% of cases (about 6 weeks on average)
- vaginal bleeding - from spotting to the equivalent of a normal menstrual period - in 50-80% of cases; it is due to a low production of hCG by the ectopic trophoblast
- abdominal pain - from vague lower abdominal discomfort to generalised abdominal pain - in 90% of cases
Unfortunately these typical symptoms are also commonly observed in viable (50%), nonviable (25%) intrauterine pregnancies, in threatened abortion, in cervical irritation, in infection and in trauma (1).
A high degree of suspicion is required if a clinician has to diagnose ectopic pregnancy since symptoms like abdominal pain or vaginal bleeding may be vague and may even be asymptomatic until the patient presents with symptoms of tubal rupture (2).
Less common presenting symptoms include:
- pain radiating to the shoulder secondary to diaphragmatic irritation (3)
- diarrhoea, vomiting and collapse (4)
On physical examination there can be
- lower abdominal and adnexal tenderness
- cervical motion tenderness
- peritoneal signs
- adnexal masses - palpable in less than 10% of patients
- symptoms of hemodynamic compromise (hypotension, shock) – now seen less commonly due to early detection of ectopic pregnancies (1).
NICE have also outlined possible clinical features of ectopic pregnancy - these include (5):
- Possible symptoms
- common symptoms:
- abdominal or pelvic pain
- amenorrhoea or missed period
- vaginal bleeding with or without clots
- other reported symptoms:
- breast tenderness
- gastrointestinal symptoms
- dizziness, fainting or syncope
- shoulder tip pain
- urinary symptoms
- passage of tissue
- rectal pressure or pain on defecation
- be aware that ectopic pregnancy can present with a variety of signs on examination by a healthcare professional.
- possible signs of ectopic pregnancy include:
- more common signs:
- pelvic tenderness
- adnexal tenderness
- abdominal tenderness
- other reported signs:
- cervical motion tenderness
- rebound tenderness or peritoneal signs
- pallor
- abdominal distension
- enlarged uterus
- tachycardia (more than 100 beats per minute) or hypotension (less than 100/ 60 mmHg)
- shock or collapse
- orthostatic hypotension.
Notes (5):
- During clinical assessment of women of reproductive age, be aware that:
- they may be pregnant, and think about offering a pregnancy test even when symptoms are non-specific and
- the symptoms and signs of ectopic pregnancy can resemble the common symptoms and signs of other conditions - for example, gastrointestinal conditions or urinary tract infection.
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