Ectopic Pregnancy

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Introduction   

An ectopic pregnancy is a potentially life-threatening medical condition that can result in high client mortality if left untreated. It’s important for nurses and healthcare providers to recognize the signs and symptoms of an ectopic pregnancy, diagnostic testing, treatment, and potential complications. This course aims to equip learners with knowledge related to an ectopic pregnancy by reviewing its definition, epidemiology, pathophysiology, and etiology. This course also describes the signs and symptoms, diagnostic tests, and medical versus surgical treatment. Lastly, it reviews potential complications and provides client education considerations. 

Definitions 

Ectopic pregnancy is a potentially life-threatening pregnancy complication that results when an embryo implants outside of the uterine cavity. The most common site where this incorrect implantation occurs is in the fallopian tube [6]. 

Heterotopic pregnancy occurs when a client has an ectopic pregnancy alongside an intrauterine pregnancy [6, 8]. 

Epidemiology 

It’s estimated that around 1% to 2% of people who become pregnant will have an ectopic pregnancy [6]. Some reports suggest that 25 out of every 1,000 pregnancies in the United States are ectopic pregnancies, which has drastically increased since 1970 [7]. 

Interestingly, the most common site for incorrect implantation to occur during an ectopic pregnancy is the fallopian tube, accounting for about 90%-96% of cases [6, 11]. Furthermore, less than 10% of ectopic pregnancies occur outside the fallopian tube, and roughly 4% are cesarean scar ectopic pregnancies [6]. Some sources report that heterotopic pregnancies occur in about 1 out of every 10,000 to 30,000 pregnancies [8]. 

Clients who are pregnant multiple times are at increased risk for developing an ectopic pregnancy. The risk of ectopic pregnancy in the United States is higher, almost double, for other races compared to White women. The mortality rate with ectopic pregnancy is high since ectopic pregnancy can rupture and cause an internal hemorrhage. Additionally, the risk of death is higher in the Black population than in the White population, where some studies report Black Americans are seven times more likely to die from an ectopic pregnancy [7, 11].  

Pathophysiology 

An ectopic pregnancy is when an embryo implants outside of the uterine cavity. It can occur in places like the fallopian tubes, cervix, myometrium, ovaries, abdominal cavity, and other places [6]. For an ectopic pregnancy to occur, the ovum must be fertilized, and abnormal implantation occurs [7]. There are many factors that contribute to the development of an ectopic pregnancy. It’s thought that fallopian tube damage comes from secondary causes, like surgery, pelvic inflammatory disease, tubal dysfunction, etc. This damage interferes with the smooth muscles and ciliary movement of the fallopian tubes, which delays or stops embryo transport [6].  

Etiology and Risk Factors 

There are many risk factors that contribute to the development of an ectopic pregnancy. Some of these include [3, 4, 5, 7, 8, 11]: 

• History of pelvic inflammatory disease or sexually transmitted infections 

• History of endometriosis 

• History of multiple sexual partners 

• History of abdominal or gynecological surgeries 

• History of assisted reproductive technologies 

• Increasing age (age over 35) 

• Cigarette smoking: Smoking increases a client’s risk since it causes decreased fallopian tube ciliary function. 

Additionally, clients with a prior ectopic pregnancy or infertility are at increased risk for ectopic pregnancy [3, 7]. Some reports suggest that clients with a history of ectopic pregnancy are three to eight times more likely to develop an ectopic pregnancy compared to other clients who do not have a prior history [11]. Also, frequent vaginal douching has also been linked to an increase in risk of ectopic pregnancy [11]. 

Clinical Manifestations 

The signs and symptoms of an ectopic pregnancy vary per individual and are most commonly present during the first trimester, or 6-8 weeks, of pregnancy. Clients often present with vaginal bleeding and/or abdominal/pelvic pain. However, some clients are completely asymptomatic [4, 10]. Although clients present with the classic triad of symptoms, including pain, vaginal bleeding, and amenorrhea, this only occurs in about 50% of cases [7]. With a wide array of symptoms, nurses and healthcare providers should consider an ectopic pregnancy diagnosis in their differential, especially in clients with confirmed pregnancy but who have not received an ultrasound to confirm whether it’s intrauterine. Additionally, clients who have undergone in vitro fertilization or who may be pregnant due to lack of recent menstrual cycle (absence of menses for more than 4 weeks) [10]. Other symptoms of ectopic pregnancy may include [7, 8, 10]: 

• Nausea and/or vomiting 

• Fatigue 

• Breast tenderness 

• Dyspareunia (painful intercourse) 

• Abdominal/pelvic cramping 

If the ectopic pregnancy ruptures, the client may also present with signs of hemorrhagic shock or peritoneal irritation. Some of these symptoms include [5, 7, 8]: 

• Fever 

• Sudden, severe abdominal/pelvic pain 

• Dizziness or weakness 

• Presyncope or syncope 

Interestingly, shoulder pain is a common sign of peritoneal irritation [7].  

Clients may also develop signs and physical exam findings consistent with ectopic pregnancy. Again, however, these vary per individual. Unilateral or bilateral lower abdominal or pelvic tenderness is common. Upon careful bimanual pelvic exam, the client will exhibit cervical and adnexal motion tenderness on the affected side. Sometimes, there is a palpable adnexal mass [7, 8]. Clients with hemorrhagic/hypovolemic shock will have low blood pressure and tachycardia. However, some clients will not be tachycardic [5,7]. Presyncope and/or syncope are signs of hemorrhagic shock, and abdominal rigidity, severe tenderness, and guarding are peritoneal signs [7, 8].  

Diagnostic Tests and Diagnosis 

If an ectopic pregnancy is suspected, then diagnostic tests are ordered to confirm the diagnosis. If the client is in an outpatient setting, then they should be immediately sent or transferred to the emergency room for immediate evaluation and a STAT workup. Initial diagnostic tests typically include serum beta-human chorionic gonadotropin (beta-hCG) levels and transvaginal ultrasound [2, 6, 8]. In ectopic pregnancy cases, usually, the serum beta-hCG will abnormally rise. In normal uterine pregnancies, the beta-hCG doubles about every 48-72 hours, but in ectopic pregnancies, it’s far less [7, 10].  

Beta-hCG levels alone cannot be used to diagnose an ectopic pregnancy. Therefore, healthcare providers should compare hCG levels with the transvaginal ultrasound findings. Also, healthcare providers should follow the hCG discriminatory zone, where the “serum hCG level is above which a gestational sac should be visualized when an intrauterine pregnancy is present” [10]. This discriminatory zone level has varying standards, with some sources ranging from 1,500 to 2,000 mIU/mL [2], while others recommend a zone of 3,510 mIU/mL [10] or 3,500 mIU/mL when using a transvaginal ultrasound [3]. 

A transvaginal ultrasound should also be ordered on the client to visualize the extrauterine gestational sac and if there is any bleeding.  Ultrasound findings that can indicate possible ectopic pregnancy are an empty uterine cavity or a pseudo-gestational sac with elevated beta-hCG levels at a specific level. Also, a decidual cast or thick echogenic endometrium can indicate an ectopic pregnancy [2, 10]. 

A transvaginal ultrasound is the most reliable method to confirm an ectopic pregnancy, where an extrauterine gestational sac is found. However, this is not found in the majority of ectopic pregnancy cases. Again, this is why healthcare providers must consider beta-hCG levels in combination with ultrasound findings [2, 10]. There are three methodologies that an ectopic pregnancy can be confirmed, which include: 

1. Transvaginal ultrasound reveals an extrauterine gestational sac [10]. 
2. “Positive serum beta-hCG levels and no products of conception on uterine aspiration with subsequent rising or plateauing hCG levels” [10]. 
3. Surgery to remove the tissue with histologic confirmation [10]. 

If the client is stable and there is not a confirmed ectopic pregnancy, the provider should complete serial beta-hCG levels. This can be done on an outpatient basis. If beta-hCG levels abnormally rise, an ectopic pregnancy or potentially a spontaneous abortion is likely [8]. 

A transabdominal ultrasound may also be considered as a diagnostic test but provides less detail than a transvaginal ultrasound. A transabdominal ultrasound is sometimes used to screen for an intraperitoneal hemorrhage [10]. Also, if a heterotopic pregnancy is suspected, then a transvaginal ultrasound is warranted [2]. 

Additional tests are also ordered, which help guide treatment decision-making and next steps in care. Some of these include a complete blood count (CBC), comprehensive metabolic panel (CMP), blood type and crossmatch, and Rh typing [7, 10]. Blood type and Rh factor help determine if the client needs a RhoGAM shot and also that blood products are available in case of rupture [7]. For clients who are hemodynamically unstable or who have a ruptured ectopic pregnancy with hemorrhage, additional tests may be ordered [7, 10]. Some of these tests may include progesterone levels, estradiol, creatinine kinase, and other markers [7]. Again, however, these are not routinely ordered. 

Treatment 

Once the diagnosis is made, treatment should be promptly initiated. Treatment is dependent on the ultrasound findings and the client’s hemodynamic stability. Regardless, an ectopic pregnancy is or can become a life-threatening emergency and warrants prompt treatment. Therefore, a STAT consult with an obstetrician is necessary to determine the best course of treatment for the client [7, 9]. 

For clients who are hemodynamically stable and have no evidence of ectopic pregnancy rupture, they can be either medically or surgically managed. The obstetrician must discuss and weigh the pros and cons of both treatment methods with the client [3, 9].  

For clients who are medically managed, methotrexate is the only approved medication for the treatment of an ectopic pregnancy. However, there are several contraindications to this medication, including renal insufficiency, anemia, liver disease, and others. Also, if the client has a heterotopic pregnancy, methotrexate is contraindicated. The provider must review these contraindications and lab values with the client prior to administration. Again, the reason a complete blood count and comprehensive metabolic panel are performed on the client is to screen for potential contraindications of methotrexate administration and assess hemodynamic stability. If the client is a candidate for methotrexate, they will receive an intramuscular injection of the medication and can be followed in an outpatient setting [3, 12]. The client may receive either a single or double dose of the medication, which is determined by the client’s ultrasound findings and beta-hCG levels [1, 3].  

One meta-analysis study’s results reported that the two-dose protocol for methotrexate was superior when compared to the single-dose method [1]. However, the American Academy of Family Physicians has specific methotrexate dosing guidelines. Subsequent serial beta-hCG levels should be ordered on day 4 and day 7, and if levels do not decline between days 4 and 7, then another dose of methotrexate may be considered, or surgical treatment may be performed. As clients who are medically managed are treated in an outpatient setting, close follow-up is required. Clients should be educated on the risks and signs of rupture and the importance of follow-up and compliance [3].  

For clients where methotrexate is contraindicated, have a ruptured ectopic pregnancy, or are hemodynamically unstable, surgery is the recommended treatment. Also, surgery is indicated if the client exhibits peritoneal signs, there is fluid in the cul-de-sac, or there is fetal cardiac activity. There are other cases where surgical management may be client-preferred [3,9]. Laparoscopic surgery is recommended for clients who are stable, and a salpingotomy or salpingectomy is performed. This depends on the location of the ectopic pregnancy, if it has ruptured, and other factors [6, 8]. 

In addition, clients who are Rh-negative, regardless of their treatment method, should receive a Rho(D) immune globulin, also called a RhoGAM injection [8]. Clients who are hemodynamically unstable or with excess blood loss may require a blood transfusion and other vital sign support [9].  

Potential Complications 

Although the prognosis for clients who are treated for an ectopic pregnancy is high, potential complications may arise. This is the reason clients require close follow-up, especially in an outpatient setting. Potential complications include tubal rupture, tubal abortion, and spontaneous abortion [6, 10]. Also, clients who have surgery may have surgical complications or other complications that develop from hemodynamic instability [6]. 

Client Education and Follow-up 

Client education is a vital component of client care and treatment planning. Clients who are medically managed with methotrexate should receive education about the medication. They should receive counseling on avoiding folic acid supplements and NSAIDs since these can reduce the effectiveness of methotrexate. Also, they should avoid activities that can increase the risk of rupture [3]. Ensuring the client understands the importance of continued follow-up and repeat beta-hCG levels is also crucial to client compliance and outcomes [3, 6, 7]. Clients treated in an outpatient setting should also be instructed on the warning signs of an ectopic rupture, like sudden severe abdominal pain, dizziness, presyncope, syncope, and others. They should understand that these signs warrant emergency evaluation and surgical management [5, 7, 8]. 

Clients who undergo surgery should also be counseled on the benefits and risks of surgery and potential complications. Follow-up with the obstetrical surgeon after hospital discharge is also required [6, 7]. 

Conclusion

Although the percentage of ectopic pregnancy in the general population remains low, its incidence has increased over the last several decades [7]. Therefore, nurses and healthcare providers must be diligent and able to recognize the signs and symptoms of this condition, along with the importance of prompt intervention. A thorough history and physical exam must be completed to help guide the possible diagnosis. Prompt diagnostic testing, consultation with an obstetrician, and medical or surgical management are essential components of managing these clients.   

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