Ectopic pregnancy: 'classic' vs common presentation

Abstract

Ectopic pregnancies are common, are increasing in incidence, and are preventable causes of reproductive morbidity and death. They are also frequently misdiagnosed, and are one of the most common causes for malpractice claims made against primary care physicians. The classic description of the presenting signs and symptoms of ectopic pregnancy was derived from a series of ruptured ectopic pregnancies. To decrease the complications and preserve fertility, ectopic pregnancies must be detected before they cause tubal rupture. A family medicine center experience with the diagnosis of ectopic pregnancy over a six-month period is presented. The study confirmed the expected frequency of this condition in this population but findings disclosed that the classic presentation was, in fact, uncommon. Implications for decision making derived from these case reports are discussed. A high level of clinical suspicion for this problem must be maintained.

PIP: To illustrate the way in which cases of ectopic pregnancy present in a family practice setting in contrast to the hospital setting, 7 case reports of ectopic pregnancy are reviewed. A 6-month study of ectopic pregnancies conducted at the Duke-Watts Family Medical Center showed that the classic symptoms of ectopic pregnancy occur uncommonly and to wait for some or all of the triad of symptoms delays diagnosis and treatment. The cases reported highlight the way women present with a tubal pregnancy that has not yet ruptured the fallopian tubes. None of these women presented with the classic triad of symptoms -- aberrant menses, abdominal pain, and an adnexal mass. 4 of 7 patients had risk factors for ectopic pregnancy, and 5 women had an aberrant menstrual pattern. The only woman who did not have vaginal bleeding was the woman whose tube had ruptured. None of these women has an adnexal mass when seen initially. The woman who experienced classic pain also had the ruptured fallopian tube. In 4 cases there was reluctance to consider the diagnosis. In 2 cases in which the diagnosis was considered, a less sensitive pregnancy test -- the urine test -- was ordered. Surgically, 1 tube was preserved intact. 2 other women had conservative operative procedures performed in the hope of optimizing their future fertility. A more comprehensive evaluation of pelvic complaints should be performed when risk factors such as prior ectopic pregnancies or pelvic inflammatory disease are reported. If pregnancy is diagnosed, its location needs to be ascertained by ultrasound examination. Contraceptive use does not rule out the possibility of an ectopic pregnancy, and a pregnancy, under these conditions, is more likely to be ectopic. A physician needs to insist on pathologic examination of all abortions. Exclusion of an ectopic pregnancy is indicated if no products of conception are found. There needs to be prompt referral to allow for conservative tubal surgery in cases of ectopic pregnancies diagnosed prior to rupture.