25/08/13

Ectopic Pregnancy Clinical Presentation

pemberian asam askorbat pada KPD

Today News Reference Education Log Out My Account Dr. D Sumarli

Search

Ectopic Pregnancy Clinical Presentation

Author: Vicken P Sepilian, MD, MSc; Chief Editor: Michel E Rivlin, MD more... Updated: May 6, 2013

History
The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding; unfortunately, only about 50% of patients present with all 3 symptoms. About 40-50% of patients with an ectopic pregnancy present with vaginal bleeding, 50% have a palpable adnexal mass, and 75% may have abdominal tenderness. In one case series of ectopic pregnancies, abdominal pain presented in 98.6% of patients, amenorrhea in 74.1% of them, and irregular vaginal bleeding in 56.4% of patients.[46] These symptoms overlap with those of spontaneous abortion; a prospective, consecutive case series found no statistically significant differences in the presenting symptoms of patients with unruptured ectopic pregnancies versus those with intrauterine pregnancies.[47] In first-trimester symptomatic patients, pain as the presenting symptom is associated with an odds ratio of 1.42, and moderate to severe vaginal bleeding at presentation is associated with an odds ratio of 1.42 for ectopic pregnancy.[48] In one study, 9% of patients with ectopic pregnancy presented with painless vaginal bleeding.[49] As a result, almost 50% of cases of ectopic pregnancy are not diagnosed at the first prenatal visit. Patients may present with other symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia. Painful fetal movements (in the case of advanced abdominal pregnancy), dizziness or weakness, fever, flulike symptoms, vomiting, syncope, or cardiac arrest have also been reported. Shoulder pain may be reflective of peritoneal irritation. Astute clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness. Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. Fortunately, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed before rupture.

Physical Examination
The physical examination of patients with ectopic pregnancy is highly variable and often unhelpful. Patients frequently present with benign examination findings, and adnexal masses are rarely found. Patients in hemorrhagic shock from ruptured ectopic may not be tachycardic.[50] Some physical findings that have been found to be predictive (although not diagnostic) for ectopic pregnancy include the following: Presence of peritoneal signs Cervical motion tenderness Unilateral or bilateral abdominal or pelvic tenderness - Usually much worse on the affected side
emedicine.medscape.com/article/2041923-clinical#showall 1/6

25/08/13

Ectopic Pregnancy Clinical Presentation

Abdominal rigidity, involuntary guarding, and severe tenderness, as well as evidence of hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases. However, midline abdominal tenderness or a uterine size of greater than 8 weeks on pelvic examination decreases the risk of ectopic pregnancy.[51] On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary. The presence of uterine contents in the vagina, which can be caused by shedding of endometrial lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an incomplete or complete abortion and therefore a delayed or missed diagnosis of ectopic pregnancy.

Contributor Information and Disclosures

Author Vicken P Sepilian, MD, MSc Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center Vicken P Sepilian, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine Disclosure: Nothing to disclose. Coauthor(s) Ellen Wood, DO, FACOOG Voluntary Assistant Professor, University of Miami, Leonard M Miller School of Medicine Ellen Wood, DO, FACOOG is a member of the following medical societies: American Society for Reproductive Medicine Disclosure: Nothing to disclose. Chief Editor Michel E Rivlin, MD Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Obstetricians and Gynaecologists, and Royal College of Surgeons of Edinburgh Disclosure: Nothing to disclose. Additional Contributors A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah) A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Robert K Zurawin, MD Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic
emedicine.medscape.com/article/2041923-clinical#showall 2/6

25/08/13

Ectopic Pregnancy Clinical Presentation

Laparoscopists, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Texas Medical Association Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

References
1. Farquhar CM. Ectopic pregnancy. Lancet. Aug 13-19 2005;366(9485):583-91. [Medline]. 2. Barclay L. Transvaginal Sonogram May Be Best Test for Ectopic Pregnancy. Medscape Medical News, April 2013. Available at http://www.medscape.com/viewarticle/802998. Accessed April 29, 2013. 3. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. Apr 24 2013;309(16):1722-9. [Medline]. 4. Kadar N, Bohrer M, Kemmann E, Shelden R. The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study. Fertil Steril. Jun 1994;61(6):1016-20. [Medline]. 5. Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. Dec 2010;56(6):674-83. [Medline]. 6. Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol. Mar 2010;115(3):495-502. [Medline]. 7. Lipscomb GH. Medical therapy for ectopic pregnancy. Semin Reprod Med. Mar 2007;25(2):93-8. [Medline]. 8. Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol. May 1991;77(5):754-7. [Medline]. 9. Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year populationbased study of 1800 cases. Hum Reprod. Dec 2002;17(12):3224-30. [Medline]. 10. Saito M, Koyama T, Yaoi Y, Kumasaka T, Yazawa K. Site of ovulation and ectopic pregnancy. Acta Obstet Gynecol Scand. 1975;54(3):227-30. [Medline]. 11. Nkusu Nunyalulendho D, Einterz EM. Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946. Rural and Remote Health 8 (online). 2008;1087;[Full Text]. 12. Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a metaanalysis. Fertil Steril. Jun 1996;65(6):1093-9. [Medline]. 13. Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril. Feb 1999;71(2):282-6. [Medline]. 14. Bouyer J, Coste J, Shojaei T, Pouly JL, Fernandez H, Gerbaud L, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol. Feb 1 2003;157(3):185-94. [Medline]. 15. Fylstra DL. Ectopic pregnancy after hysterectomy: a review and insight into etiology and prevention. Fertil Steril. Jul 2010;94(2):431-5. [Medline]. 16. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med. Mar 13 1997;336(11):762-7. [Medline]. 17. Furlong LA. Ectopic pregnancy risk when contraception fails. A review. J Reprod Med. Nov 2002;47(11):881-5. [Medline]. 18. Sivin I. Dose- and age-dependent ectopic pregnancy risks with intrauterine contraception. Obstet
emedicine.medscape.com/article/2041923-clinical#showall 3/6

25/08/13

Ectopic Pregnancy Clinical Presentation

Gynecol. Aug 1991;78(2):291-8. [Medline]. 19. Vinson DR. Emergency contraception and risk of ectopic pregnancy: is there need for extra vigilance?. Ann Emerg Med. Aug 2003;42(2):306-7. [Medline]. 20. Dor J, Seidman DS, Levran D, Ben-Rafael Z, Ben-Shlomo I, Mashiach S. The incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization and embryo transfer. Fertil Steril. Apr 1991;55(4):833-4. [Medline]. 21. Svare JA, Norup PA, Thomsen SG, Hornnes PJ, Maigaard S, Helm P, et al. [Heterotopic pregnancy after in vitro fertilization]. Ugesk r Laeger. Apr 11 1994;156(15):2230-3. [Medline]. 22. Majmudar B, Henderson PH 3rd, Semple E. Salpingitis isthmica nodosa: a high-risk factor for tubal pregnancy. Obstet Gynecol. Jul 1983;62(1):73-8. [Medline]. 23. Hoover RN, Hyer M, Pfeiffer RM, et al. Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J Med. Oct 6 2011;365(14):1304-14. [Medline]. 24. Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy--United States, 19701989. MMWR CDC Surveill Summ. Dec 17 1993;42(6):73-85. [Medline]. 25. Zane SB, Kieke BA Jr, Kendrick JS, Bruce C. Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States. Matern Child Health J . Dec 2002;6(4):22736. [Medline]. 26. Caldern JL, Shaheen M, Pan D, Teklehaimenot S, Robinson PL, Baker RS. Multi-cultural surveillance for ectopic pregnancy: California 1991-2000. Ethn Dis . Autumn 2005;15(4 Suppl 5):S5-20-4. [Medline]. 27. Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol. May 2005;105(5 Pt 1):1052-7. [Medline]. 28. Goyaux N, Leke R, Keita N, Thonneau P. Ectopic pregnancy in African developing countries. Acta Obstet Gynecol Scand. Apr 2003;82(4):305-12. [Medline]. 29. Lewis G, ed. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London, UK: The Confidential Enquiry into Maternal and Child Health (CEMACH). 2007:92-3. .. 30. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. Feb 21 2003;52(2):1-8. [Medline]. 31. Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. Mar 1997;67(3):421-33. [Medline]. 32. Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy - the laparoscopic surgical choice for ectopic pregnancy. Hum Reprod. Jun 1996;11(6):1199-203. [Medline]. 33. Clausen I. Conservative versus radical surgery for tubal pregnancy. A review. Acta Obstet Gynecol Scand. Jan 1996;75(1):8-12. [Medline]. 34. Maymon R, Shulman A, Halperin R, Michell A, Bukovsky I. Ectopic pregnancy and laparoscopy: review of 1197 patients treated by salpingectomy or salpingotomy. Eur J Obstet Gynecol Reprod Biol. Sep 1995;62(1):61-7. [Medline]. 35. Parker J, Bisits A. Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?. Aust N Z J Obstet Gynaecol. Feb 1997;37(1):115-7. [Medline]. 36. Ory SJ, Nnadi E, Herrmann R, O'Brien PS, Melton LJ 3rd. Fertility after ectopic pregnancy. Fertil Steril. Aug 1993;60(2):231-5. [Medline]. 37. Rulin MC. Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy?. Obstet Gynecol. Dec 1995;86(6):1010-3. [Medline]. 38. Stovall TG, Ling FW, Carson SA, Buster JE. Serum progesterone and uterine curettage in differential diagnosis of ectopic pregnancy. Fertil Steril. Feb 1992;57(2):456-7. [Medline].
emedicine.medscape.com/article/2041923-clinical#showall 4/6

25/08/13

Ectopic Pregnancy Clinical Presentation

39. Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a metaanalysis comparing "single dose" and "multidose" regimens. Obstet Gynecol. Apr 2003;101(4):778-84. [Medline]. 40. Alleyassin A, Khademi A, Aghahosseini M, Safdarian L, Badenoosh B, Hamed EA. Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial. Fertil Steril. Jun 2006;85(6):16616. [Medline]. 41. Barnhart KT, Sammel MD, Hummel A, Jain J, Chakhtoura N, Strauss J. A novel "two dose" regimen of methotrexate to treat ectopic pregnancy. Fertil Steril. 2005;84(Suppl):S130. 42. Ectopic pregnancy mortality - Florida, 2009-2010. MMWR Morb Mortal Wk ly Rep. Feb 17 2012;61(6):1069. [Medline]. 43. Anderson FW, Hogan JG, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet Gynecol. Jun 2004;103(6):1218-23. [Medline]. 44. Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. Jan 2006;194(1):92-4. [Medline]. 45. Khan KS, Wojdyla D, Say L, Glmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. Apr 1 2006;367(9516):1066-74. [Medline]. 46. Alsuleiman SA, Grimes EM. Ectopic pregnancy: a review of 147 cases. J Reprod Med. Feb 1982;27(2):101-6. [Medline]. 47. Stovall TG, Kellerman AL, Ling FW, Buster JE. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med. Oct 1990;19(10):1098-103. [Medline]. 48. Barnhart KT, Sammel MD, Gracia CR, Chittams J, Hummel AC, Shaunik A. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertil Steril. Jul 2006;86(1):36-43. [Medline]. 49. Kaplan BC, Dart RG, Moskos M, Kuligowska E, Chun B, Adel Hamid M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. Jul 1996;28(1):10-7. [Medline]. 50. Abbott J, Emmans LS, Lowenstein SR. Ectopic pregnancy: ten common pitfalls in diagnosis. Am J Emerg Med. Nov 1990;8(6):515-22. [Medline]. 51. Dart RG, Kaplan B, Varaklis K. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med. Mar 1999;33(3):283-90. [Medline]. 52. Huchon C, Panel P, Kayem G, et al. Is a Standardized Questionnaire Useful for Tubal Rupture Screening in Patients With Ectopic Pregnancy?. Acad Emerg Med. Jan 5 2012;[Medline]. 53. Mol F, van den Boogaard E, van Mello NM, van der Veen F, Mol BW, Ankum WM, et al. Guideline adherence in ectopic pregnancy management. Hum Reprod. Feb 2011;26(2):307-15. [Medline]. 54. Shepherd RW, Patton PE, Novy MJ, Burry KA. Serial beta-hCG measurements in the early detection of ectopic pregnancy. Obstet Gynecol. Mar 1990;75(3 Pt 1):417-20. [Medline]. 55. Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. Jul 2004;104(1):50-5. [Medline]. 56. Condous G, Kirk E, Lu C, Van Huffel S, Gevaert O, De Moor B, et al. Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location. Ultrasound Obstet Gynecol. Dec 2005;26(7):770-5. [Medline]. 57. Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol. Dec 1994;84(6):1010-5. [Medline]. 58. Verma U, English D, Brookfield K. Conservative management of nontubal ectopic pregnancies. Fertil Steril. Dec 2011;96(6):1391-1395.e1. [Medline].
emedicine.medscape.com/article/2041923-clinical#showall 5/6

25/08/13

Ectopic Pregnancy Clinical Presentation

59. Stovall TG, Ling FW, Carson SA, Buster JE. Serum progesterone and uterine curettage in differential diagnosis of ectopic pregnancy. Fertil Steril. Feb 1992;57(2):456-7. [Medline]. 60. Menon S, Colins J, Barnhart KT. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril. Mar 2007;87(3):481-4. [Medline]. 61. Thurman AR, Cornelius M, Korte JE, Fylstra DL. An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy. Am J Obstet Gynecol. Feb 2010;202(2):139.e1-6. [Medline]. 62. Medical treatment of ectopic pregnancy. Fertil Steril. Nov 2008;90(5 Suppl):S206-12. [Medline]. Medscape Reference 2011 WebMD, LLC

emedicine.medscape.com/article/2041923-clinical#showall

6/6