This case study will examine the assessment and management of a patient presenting to the Emergency Department with severe abdominal pain and small vaginal bleeding in the first trimester of pregnancy. The case study will allow participants to understand the significance of ectopic pregnancy, the consequences of mis-diagnosis, the gynaecological assessment of a patient presenting with symptoms of abdominal pain and/or vaginal bleeding (with or without a prior known positive pregnancy test), the investigative tests required, and the options for management once a diagnosis is made.
At the completion of this module, participants will be able to:
Define ectopic pregnancy and state the risk factors for ectopic pregnancy
Identify the signs and symptoms of ectopic pregnancy
Describe the principles of assessment and management of a patient presenting with pain and bleeding in the first trimester
Identify the options for management of an ectopic pregnancy
Appreciate the emotional, psychological and physical impact of an ectopic pregnancy for the patient and their family, and identify appropriate support services
An ectopic pregnancy occurs when a fertilized egg implants somewhere other than the main cavity of the uterus. Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches itself to the lining of the uterus. An ectopic pregnancy most often occurs in one of the tubes that carry eggs from the ovaries to the uterus (fallopian tubes). This type of ectopic pregnancy is known as a tubal pregnancy. In some cases, however, an ectopic pregnancy occurs in the abdominal cavity, ovary or neck of the uterus (cervix). An ectopic pregnancy can't proceed normally. The fertilized egg can't survive, and the growing tissue might destroy various maternal structures. Left untreated, life-threatening blood loss is possible. Early treatment of an ectopic pregnancy can help preserve the chance for future healthy pregnancies. Up to 10% of women with ectopic pregnancy have no symptoms, and one-third have no medical signs. In many cases the symptoms have low specificity, and can be similar to those of other genitourinary and gastrointestinal disorders, such as appendicitis, salpingitis, rupture of a corpus luteum cyst, miscarriage, ovarian torsion or urinary tract infection. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability. Signs and symptoms of ectopic pregnancy include vaginal bleeding (in varying amounts), abdominal pain, pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness. In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage. Nausea, vomiting and diarrhea are more rare symptoms of ectopic pregnancy. Rupture of an ectopic pregnancy can lead to symptoms such as abdominal distension, tenderness, peritonism and hypovolemic shock. A woman with ectopic pregnancy may be excessively mobile with upright posturing, in order to decrease intrapelvic blood flow, which can lead to swelling of the abdominal cavity and cause additional pain.