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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