There is no one classical presentation of EPL; it commonly occurs without symptoms or with one or more of the following:
- Vaginal bleeding (the most common sign)
- Abdominal cramping, pelvic or back pain
- Passing of tissue from the vagina
- Loss of pregnancy related symptoms (breast tenderness, nausea)
- Constitutional symptoms such as fever or malaise
Though vaginal bleeding is the most common sign, it does not always signify EPL:
- 30% of normal pregnancies have vaginal bleeding.
- 50% ongoing pregnancy rate with isolated bleeding and closed cervix.
- 85% ongoing pregnancy rate with confirmation of fetal cardiac activity.
Evaluation should include a physical examination, ultrasound (US), and/or quantitative hCGs. Serial hCGs are most helpful when US is inconclusive (i.e. pregnancy of unknown location), and are unnecessary if US confirms an intrauterine EPL.
Physical exam helps assess the patient’s status and offer diagnostic clues, and should include:
- Vital signs (including orthostatics if symptomatic or with heavy bleeding)
- Abdominal examination (to rule out peritonitis or other causes for symptoms)
- Pelvic examination (for bleeding, cervical dilatation, tenderness)
Tissue examination (for clot vs. pregnancy tissue)
Diagnosis of EPL is confirmed by one of the following:
- US confirmation of anembryonic gestation or embryonic/fetal demise in the intrauterine cavity (Ch 3)
- Absence of previously seen IUP on US
- Tissue exam confirming membranes and villi expelled or removed from uterus.
Diagnosis of EPL is also suggested by clinical history suggesting EPL with rapidly declining hCGs and no IUP on US.
In all patients presenting with first trimester bleeding, ectopic pregnancy should be considered. Ectopic pregnancies often present with vaginal spotting, frequently occurring at 6-8 weeks gestation. Due to the implantation of an ectopic pregnancy at sites ill-equipped to support the nourishment of a growing pregnancy, levels of hCG can be insufficient to support the corpus luteum, eventually causing sloughing of the endometrial lining. In the interim, levels of hCG can rise or can fall. In addition to vaginal bleeding, other signs and symptoms of ectopic pregnancy include abdominal pain and/or rebound tenderness, referred shoulder pain, and syncope.
Remember two critical aspects of the evaluation in a patient with signs or symptoms of EPL:
- Ensure hemodynamic stability, and manage or refer as appropriate
- Evaluate for ectopic pregnancy, and treat or refer as appropriate
The commonly used algorithm below uses a minimum expected hCG increase of 53% over 2 days to characterize a viable IUP, and a decline of 35-50% over 2 days to characterize a completed EPL (Butts 2013, Prine 2011, Barnhart 2009). Studies have shown that the change in hCG level for patients experiencing an IUP, ectopic pregnancy, or EPL is quite nuanced. For patients with a viable IUP, while the traditional expected increase in hCG is to double every 48 hours, the change in hCG level over 2 days can increase as little as 35% (99.9% sensitive) (Butts 2013). While using a threshold of a 53% increase is 99% sensitive for detecting viable IUPs, consider using a lower threshold in patients with desired pregnancies to avoid misclassification of an early IUP as an ectopic or EPL.
For patients with an initial pregnancy of unknown location (PUL), the ability to predict an ectopic pregnancy is increased if a third hCG level is obtained on day 4 or 7 if the first two levels (day 0 and day 2) are suggestive of an IUP or EPL (Zee 2014). Due to overlap in levels between these diagnoses (as seen in the Chapter 3 Figure, hCG levels must always be correlated with the full clinical picture.