Differential Diagnosis of Ectopic Pregnancy - Morbidity and Mortality

The term ectopic pregnancy refers to a gestation in which the fertilized ovum implants on any tissue other than the endometrial membrane lining the uterine cavity. Fig 1 presents the various types of ectopic pregnancy and their relative frequencies The classic clinical symptoms of ectopic pregnancy are pelvic pain, amenorrhea, and vaginal bleeding , spotting (40-50%). However, only 50% of patients present typical symptomatology. Patients may present with other symptoms common to early pregnancy, including nausea (frequently after rupture), breast fullness, fatigue, abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia . Physical findings during examination should be pelvic unilateral tenderness, especially on movement of cervix (75%), enlarged uterus or palpable adnexal mass; crepitant mass on one side or in culde-sac (50%). Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. Body temperature ranges from 37.2 to 37.8 0C while the pulse is variable: normal before but rapid after rupture. Today, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed prior to rupturing [1]. Diagnosis of ectopic pregnancy has been greatly improved by the advent of rapid serum beta-human chorionic gonadotropin (beta-HCG) tests and then the widespread adoption of transvaginal pelvic ultrasonography (TVUS) [2]. Serum beta-HCG levels can definitively rule out pregnancy if negative, although there have been case reports of pathology-proven ruptured ectopic pregnancy and hemorrhagic shock despite an undetectable serum beta-HCG [3]. In the early stages of a normal intrauterine pregnancy (IUP), the serum beta-HCG rises along a well-defined curve. Therefore, serial beta-HCG tests can be useful for determining the ultimate location of a pregnancy of unknown location. The lower limit of normal rise in beta-HCG (using a 99% confidence interval) is 53% in 2 days [4]. Patients with a beta-HCG level that falls more than 50% in 2