A-E Examination: Ruptured Ectopic Pregnancy

Practice Stations

Author – Dr Kalyani Shinkar Editor – Dr James Mackintosh

Last updated 20/08/24

Table of Contents

How to Use

Candidate:

  1. Read the brief below (1 minute). 
  2. Take a brief history and a perform a A-E examination (10 minute).
  3. Handover the patient (1 minute)
  4. Answer viva questions (2 minutes).

Patient/Examiner:

  1. Familiarise yourself with the history & examination findings 
  2. After completing the history, viva the candidate

Candidate Brief

You are an F1 in A&E. Mrs Nisha Patel is a 26-year-old woman who has presented to A&E with severe abdominal pain and vaginal bleeding. Please take a brief history and perform an A-E examination of this patient.

Presenting Complaint

  • Mrs Patel has a 4-hour history of severe sudden-onset abdominal pain in the right iliac fossa. The pain radiates to her right shoulder and is 9/10 in severity. There are no triggering, relieving, or exacerbating factors. 
  • She has vomited twice since the onset of pain. There is no blood present in the vomit.
  • She has noticed light vaginal bleeding in the last 2 hours. The blood is dark red and there are no blood clots.
  • No changes to bowel habits or urinary symptoms.
  • No fever.
  • She denies having abnormal vaginal discharge or vulvovaginal itching.

Background and Past Medical History

  • Her last menstrual period was 6 weeks ago.
  • She usually has regular periods. Her cycle length is 29 days. Her periods last 4 days on average. She denies ever having any problems with her periods, including heavy menstrual bleeding, intermenstrual bleeding, dysmenorrhoea, or post-coital bleeding. Menarche occurred at age 13.
  • She has never been pregnant. She has not had any terminations or miscarriages in the past. 
  • She is currently sexually active and has 1 long-term partner (her husband). She takes the COCP but admits to not taking it regularly.  She last took the COCP yesterday.
  • No other comorbidities

Drug History and Allergies

  • COCP
  • Nil otherwise
  • NKDA

Introduce yourself, confirm the patient’s identify, and gain consent to examine the patient

  • Patient confirms full name and DOB
  • She gives consent for you to examine her

End of bed inspection

  • She appears pale and distressed

Airways

  • Assess the patency of the patient’s airway, ensure that the patient is able to breathe effectively, and there are no airway obstructions.
    • Her airway is patent, as she is able to talk in full sentences 
    • There are no airway obstructions

Breathing

  • Inspect for signs of respiratory compromise (e.g. cyanosis, see-saw breathing, use of accessory muscles, nasal flaring, pursed lip breathing, or increased work of breathing)
    • There are no signs of respiratory compromise
  • Respiratory rate
    • RR = 20
  • O2 sats
    • O2 sats = 96% on RA
  • Palpate for tracheal deviation and symmetrical chest expansion
    • Trachea is central and there is symmetrical chest expansion
  • Percuss
    • Percussion note is resonant throughout
  • Auscultate for reduced breath sounds or added sounds
    • Vesicular breathing bilaterally
    • No added sounds

Circulation

  • Inspection (e.g. pale, sweating, clammy)
    • She appears pale
  • Temperature of hands
    • Cold
  • CRT
    • 3 seconds
  • Heart Rate
    • 120 bpm
  • Blood pressure
    • 90/65mmHg
  • Insert 2 large bore IV cannulae into each antecubital fossae
    • Take bloods (FBC for anaemia; U&Es, LFTs, and CRP for baseline; coagulation studies to check for coagulopathies, group and save & crossmatch 4 units of blood for blood transfusion, VBG to check lactate levels, and serum β-hCG levels)
    • Fluid resuscitation (500ml of 0.9% NaCl over <15 mins) 
  • JVP
    • Not raised
  • Apex beat
    • Palpable in the left 5th ICS midclavicular line
  • Heart sounds
    • Normal
  • Fluid status
    • Dry mucous membranes.
    • Last passed urine 1 hour ago.
  • Perform an ECG
    • Sinus tachycardia
  • Catheterise the patient
  • Monitor fluid input/output
  • Reassess after each intervention
    • Heart rate is 110 and blood pressure is 100/70mmHg following IV fluid bolus

Disability

  • Level of consciousness (AVPU or GCS if a neurological cause for the patient’s presentation is suspected)
    • Alert
    • Pupils
      • Equal and reactive to light
  • Blood glucose levels
    • 5.7
  • Temperature
    • 37.2°C

Exposure

  • Fully expose the patient by removing their clothing whilst preserving their dignity
  • Look for any signs of trauma, swelling, bruises, scars, rashes, or signs of a DVT
  • Abdominal examination:
    • Severe tenderness in the right iliac fossa.
    • No abdominal rigidity or guarding.
  • Bimanual examination:
    • Minimal dark red blood seen in the vaginal vault.
    • Cervical os is closed.
    • No genital tract lacerations.
    • Cervical motion tenderness and right adnexal tenderness

After completing the initial A-E assessment, reassess! Re-assess the patient to identify any additional clinical changes and effectiveness of any interventions you have performed.

1. What are your differential diagnoses?

  • Ruptured Ectopic Pregnancy (due to severe sudden-onset abdominal pain in the right iliac fossa that radiates to the right shoulder, vaginal bleeding, and possibility of pregnancy (last menstrual period was 6 weeks and she admits to inconsistent COCP use))
  • Pelvic Inflammatory Disease (important differential in a woman presenting with right iliac fossa pain. Pain can also radiate to the right shoulder in Fitz-Hugh-Curtis syndrome, a chronic manifestation of pelvic inflammatory disease)
  • Appendicitis (important differential in someone presenting with right iliac fossa pain)

2. Given a likely diagnosis of ruptured ectopic pregnancy, how would you manage this patient?

  • Call for help immediately 
  • Escalate to the obstetrics and gynaecology registrar
  • Call 2222 and state ‘obstetric emergency’
  • Do a urinary pregnancy test and check serum β-hCG levels
  • Insert 2 large bore IV cannulae and give IV fluid resuscitation and blood resuscitation as required.
  • Group and save & crossmatch 4 units of blood.
  • Consider activating the major haemorrhage protocol if the bleeding is significant. This will give rapid access to 4 units of O negative blood. 
  • Arrange for immediate transfer to theatre for definitive treatment 
  • NB - Transvaginal ultrasound (TVUS) is NOT indicated in ruptured ectopic pregnancy, as it could lead to fatal delay

3. Please Handover this patient to the obstetrics and gynaecology registrar using the SBAR or equivalent format.

  • Hi, my name is Dr. Joe Bloggs and I’m calling from A&E. Can I please confirm who I am speaking to?
  • I’m really worried about a patient I’ve just examined, I think she has a ruptured ectopic pregnancy.
  • She is a 26-year-old woman called Nisha Patel who presented with vaginal bleeding and a 4-hour history of sudden-onset abdominal pain in the right iliac fossa that radiates to the right shoulder. She has vomited twice since the onset of pain.
  • Her last menstrual period was 6 weeks ago. She has 1 regular long-term sexual partner and usually takes the COCP but admits to not taking it regularly.
  • She has no comorbidities or allergies.
  • On inspection, she appeared pale and distressed. 
  • Her airway was patent
  • Her respiratory rate was 20 and O2 sats were 96% on room air.
  • She was tachycardic and hypotensive. I inserted 2 large bore IV cannulae and have taken bloods, including FBC, U&Es, LFTs, coagulation studies, VBG, and serum β-hCG. I have given her a fluid bolus and inserted a catheter.
  • She was alert, apyrexial, and her BM was normal.
  • On examination, there was severe tenderness in the right iliac fossa. There was no rigidity or guarding. Bimanual examination revealed minimal dark red blood in the vaginal vault, cervical motion tenderness, and right adnexal tenderness. Cervical os was closed and there were no vaginal tract lacerations. 
  • I have done a pregnancy test and have put out a 2222 obstetric emergency call.
  • Can you please come and see her? In the meantime, is there anything you would like me to do?

What is an Ectopic Pregnancy?

An ectopic pregnancy is when a fertilised egg implants and grows outside the uterus, most commonly in a fallopian tube. Ectopic pregnancies are non-viable, because it is impossible for a fertilised egg to survive and grow into a baby outside the uterus. If ectopic pregnancies are not detected and treated properly, they can grow and rupture, leading to life-threatening bleeding.   

Causes and Risk Factors

In many instances of ectopic pregnancy, an exact cause cannot be identified. However, there are several risk factors associated with its development:

  • Previous ectopic pregnancy
  • Previous surgery to the fallopian tubes or scarring from previous infections, such as pelvic inflammatory disease
  • Abnormal fallopian tube anatomy, such as congenital defects or damage from surgery
  • Endometriosis can cause scarring and blockages in reproductive organs, including the fallopian tubes
  • Copper coil (IUD)
  • Smoking 
  • Older age – women over the age of 35 have a higher risk of ectopic pregnancy

Clinical Presentation

In many instances of ectopic pregnancy, an exact cause cannot be identified. However, there are several risk factors associated with its development:

  • Previous ectopic pregnancy
  • Previous surgery to the fallopian tubes or scarring from previous infections, such as pelvic inflammatory disease
  • Abnormal fallopian tube anatomy, such as congenital defects or damage from surgery
  • Endometriosis can cause scarring and blockages in reproductive organs, including the fallopian tubes
  • Copper coil (IUD)
  • Smoking 
  • Older age – women over the age of 35 have a higher risk of ectopic pregnancy

Diagnosis

The diagnosis of ectopic pregnancy requires a combination of clinical assessment, laboratory tests, and imaging studies.

Clinical Assessment: 

  • Characteristic symptoms of an ectopic pregnancy include pain in the lower abdomen or pelvis, vaginal bleeding, and a missed period or possibility of pregnancy.
  • Examination findings suggestive of ectopic pregnancy include:
    • Pelvic or lower abdominal tenderness
    • Cervical motion tenderness and/or adnexal tenderness on bimanual examination
    • Signs of haemodynamic instability (e.g. hypotension, tachycardia, prolonged CRT, pale, cold, or clammy) in cases of rupture and haemorrhage. 

Laboratory Tests:

  • A urine or blood pregnancy test needs to be performed to confirm pregnancy. 
  • Serial β-hCG 48 hours apart can indicate the possibility of ectopic pregnancy:
    • In an ectopic pregnancy, β-hCG levels may increase slightly or plateau 
    • In a normal pregnancy, the β-hCG levels typically double during the early stages of pregnancy
    • A fall in β-hCG indicates a miscarriage or suggests that the foetus will not develop 

Imaging

  • Transvaginal Ultrasound is the investigation of choice for diagnosing ectopic pregnancy, as it allows the uterus, fallopian tubes, and ovaries to be visualised in detail. In an ectopic pregnancy, the ultrasound may show an empty uterus or a gestational sac containing a yolk sac or foetal pole outside the uterus, commonly in the fallopian tube. 

Management

A suspected ectopic pregnancy requires referral to gynaecology or an early pregnancy assessment unit. The management involves terminating the pregnancy, as it is non-viable. The method for terminating an ectopic pregnancy depends on various factors such as the location and size of ectopic pregnancy, β-hCG levels, and the presence or absence of symptoms. There are 3 main approaches to managing an ectopic pregnancy:

 

Expectant Management:

  • This involves watchful waiting and close monitoring of the patient’s condition through serial β-hCG readings and repeated ultrasound examinations.
  • The NICE guidelines stipulate expectant management can be offered to women who:
    • Are clinically stable and pain free and
    • Have a tubal ectopic pregnancy <35mm with no visible heartbeat on TVUS and
    • Have a serum β-hCG levels of ≤1000 IU/L and
    • Are able to return for follow-up

Medical Management

  • This involves administering methotrexate as an IM injection into the buttocks to stop the growth of the ectopic pregnancy, enabling spontaneous termination
  • The NICE guidelines stipulate medical management can be offered to women who:
    • Have no significant pain and
    • Have an unruptured tubal ectopic pregnancy with an adnexal mass <35mm with no visible heartbeat and
    • Have a serum β-hCG levels of ≤1500 IU/L and
    • Do not have an intrauterine pregnancy (as confirmed on an US scan) and
    • Are able to return for follow-up
  • It’s important to inform women who are managed with methotrexate that their chance of requiring further intervention is increased and that they may need to be urgently admitted if their condition deteriorates.

Surgical Management

  • Most patients require surgical management for ectopic pregnancy, of which there are 2 options: laparoscopic salpingectomy and laparoscopic salpingotomy:
    • Laparoscopic Salpingectomy (1st line) is carried out under general anaesthetic and involves removal of the affected fallopian tube containing the ectopic pregnancy.
    • Laparoscopic Salpingotomy is carried out under general anaesthetic and is offered as an alternative to salpingectomy for women with risk factors for infertility caused by damage to the opposite fallopian tube.
    • Similar to methotrexate management, it’s important to inform women undergoing salpingotomy that up to 20% of cases require further treatment, which may include methotrexate and/or a salpingectomy. 
  • The NICE guidelines stipulate surgical management should be offered to women where treatment with methotrexate is not acceptable. It should also be offered as a 1st line treatment who have any of the following:
    • Are unable to return for follow-up after methotrexate treatment
    • Have an ectopic pregnancy and significant pain
    • Have an ectopic pregnancy with an adnexal mass ≥35mm
    • Have an ectopic pregnancy with a fetal heartbeat visible on an US scan
    • Have an ectopic pregnancy and a serum β-hCG level of ≥5,000 IU/L 
    • Anti-rhesus D immunoglobulin prophylaxis should be offered to all rheusus-negative women who have surgical management of their ectopic pregnancy.

Emergency Treatment for Ruptured Ectopic Pregnancy

  • If an ectopic pregnancy ruptures, emergency treatment is required. This may involve surgery to stop the bleeding and remove the ectopic pregnancy. It may also require medical treatment in the form of blood transfusions and other supportive measures to stabilise the patient. 

Follow-up Care

  • Regardless of management approach, follow-up care is crucial for after terminating an ectopic pregnancy. This may involve additional blood tests to monitor β-hCG levels, follow-up ultrasound scans to ensure the ectopic pregnancy has resolved completely, and counselling regarding future fertility and contraception options.
  1. https://teachmeobgyn.com/pregnancy/early/ectopic-pregnancy/
  2. https://www.nhs.uk/conditions/ectopic-pregnancy/

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