ous abortion. In the United States, about 2% of all pregnancies are ectopic pregnancies. Mortality in these women is due

to shock from intra-abdominal hemorrhage. In postmenopausal women with vaginal bleeding, 10% will be diagnosed

with cancer, the majority being endometrial cancer.

Ectopic pregnancy is one of the most important causes

of vaginal bleeding. Ectopic pregnancy occurs when a

1 81

• Ruptured ectopic pregnancy is a surgical emergency

requiring prompt intervention and gynecologic consultation.

• Patients with postmenopausal bleeding should be

referred to a gynecologist for endometrial biopsy to

exclude malignancy.

trophoblast implants at a site outside of the endometrium.

In most cases, the ectopic site is within the lateral two

thirds of the fallopian tube. Other sites include the medial

third of the fallopian tube, cornu (junction of the tube and

uterus), ovary, fimbria, cervix, and abdomen (Figure 43-1).

Risk factors for ectopic pregnancy include a history of salpingitis, use of an intrauterine device, a prior ectopic pregnancy, increased maternal age, use of fertility drugs, and

history of tubal ligation. Up to 42% of women with an

ectopic pregnancy have no risk factors.

CLINICAL PRESENTATION

..... History

A detailed history is essential. Determine the onset of bleeding, the date and duration of the last normal menstrual

period, the number of previous pregnancies, and the presence of any prior history of abnormal vaginal bleeding. Pain

may or may not be present. If pain is present, determine pain

characteristics such as location, quality, and duration.

Approximately 1 0% of patients with ectopic pregnancy will

present with bleeding only. Attempt to have the patient

quantify the amount of bleeding. Although variable, a

tampon or pad absorbs approximately 30 mL of blood. The

presence of clotted blood suggests brisk vaginal bleeding.

Inquire about previous gynecologic problems and

assess the risk factors for ectopic pregnancy.

CHAPTER 43

Tubal 95-96%

Interstitial and

£. Figure 43-1. Frequency of sites of ectopic pregnancy. Repri nted with permission from

Cunningham FG, Le�eno KJ, Bloom SL, Hauth JC, Rouse OJ, Spong CY. Chapter 1 o. Ectopic

Pr�g nancy. In: Cunnmgham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse OJ, Spong cv, eds.

WJ/Iwms Obstetrics. 23rd ed. New York: McGraw-Hill, 201 0.

Symptoms of weakness, lightheadedness, shortness of

breath, or syncope suggest anemia from significant blood

loss. Determine the presence of other medical conditions

(eg, coagulopathies) or medications (eg, anticoagulants)

that may exacerbate vaginal bleeding.

� Physical Examination

Note the patient's blood pressure and pulse, specifically to

identify hypotension or a resting tachycardia. Look for

other signs of anemia such as general, mucosal, or nail bed

pallor. Before performing a pelvic examination, perform a

focused general examination, including the heart, lungs,

abdomen, and flank. Assess the abdomen for the presence

of tenderness, masses, guarding, and rebound. Peritoneal

signs may suggest infection or intraperitoneal blood.

For the pelvic examination, obtain the patient's consent

and ensure her privacy during the exam. Explain what you

are going to do. Ideally, both male and female examiners

should request that a chaperone be present. Perform the

exam with the patient in the lithotomy position. First, inspect

the external genitalia. Then, using a warmed, lubricated, and

appropriately sized vaginal speculum, determine the presence of blood, blood clots, tissue (products of conception), or

discharge in the vaginal vault. Visually inspect the cervix.

On bimanual examination, determine whether the cervical os is open or closed. An open os is present when the

tip of the examiner's index finger can easily pass through

the cervix. Women with a closed internal os should be

Table 43-1. Classification of spontaneous abortion.

Type Internal Cervical Os Products of Conception

Threatened Closed Not passed

Inevitable Open Not passed

Incomplete usually open Partially passed

Complete Closed Completely passed

considered to have a closed os, even if the external portion

of the os is open. The internal os and the presence of products of conception will allow classification of different

types of spontaneous abortions ( Table 43-1).

Next, estimate the size of the uterus (12 weeks at the

symphysis, 20 weeks at the umbilicus) by palpating the

uterine fundus on the abdomen with one hand and palpating the cervix with the index and middle fingers on the

other hand. Assess the cervix, uterus, and adnexa for tenderness or masses. Tenderness on pelvic examination is

present in more than 80% of patients with a ruptured

ectopic pregnancy.

DIAGNOSTIC STUDIES

� Laboratory

Urine pregnancy test is 99.4% sensitive for diagnosing

pregnancy at the time that a woman "misses" her period.

VAGI NAL BLEEDING

It detects the presence of the beta subunit of human

chorionic gonadotropin hormone ( �-hCG) produced by

the trophoblast in the patient's urine. A serum �-hCG

level is also obtained. In a normal pregnancy, �-hCG

levels double approximately every 2 days, peaking at

1 00,000 rniU/mL. Higher levels suggest trophoblastic

disease. An ectopic pregnancy can be present at any

�-hCG level; therefore, the initial �-hCG level cannot be

used to exclude ectopic pregnancy. Patients with repeat

�-hCG levels that decrease by >50% are at low risk for

ectopic pregnancy, whereas those with levels that do not

increase >66% are at high risk.

A serum hemoglobin is indicated in most patients with

vaginal bleeding, but especially those with a resting tachycardia, lightheadedness, or prolonged duration of bleeding

(2:3 weeks). Rh status should be obtained in pregnant

patients with vaginal bleeding.

� Imaging

In pregnant patients with vaginal bleeding, the presence of

an ectopic pregnancy must be excluded with a pelvic ultrasound performed by an emergency medicine physician or

radiology personnel. Ectopic pregnancy is excluded when

an intrauterine pregnancy (IUP) is visualized on pelvic

ultrasound. A heterotopic pregnancy (a simultaneous IUP

and an ectopic pregnancy), traditionally considered rare, is

more common in women receiving treatment for infertility. Patients with pelvic ultrasounds that demonstrate a

noncystic adnexal mass, moderate-large fluid in the culde-sac, an extrauterine gestational sac, or an empty uterus

(with �-hCG > 1,000 rniU/mL) should be considered high

risk for ectopic pregnancy. In 1 5-20% of patients, the initial pelvic ultrasound will be indeterminate (no evidence

of an IUP or an ectopic pregnancy). Of these indetermi ­

nate ultrasounds, 20% eventually will be diagnosed with

an ectopic pregnancy.

MEDICAL DECISION MAKING

In a patient with vaginal bleeding, the most essential information to determine is the hemodynamic status and a

urine pregnancy test. In the pregnant patient, the most

important role of the emergency department is to exclude

an ectopic pregnancy (Figure 43-2).

In patients with vaginal bleeding during the first

trimester of pregnancy, the diagnostic possibilities

include continuation of what will be a normal

pregnancy or an abnormal pregnancy ( ie, spontaneous

abortion; ectopic pregnancy; trophoblastic disease). In

nonpregnant patients, diagnostic possibilities include

dysfunctional uterine bleeding, uterine fibroids, malig ­