Ectopic Pregnancy: A Comprehensive Physical Assessment
Introduction
Ectopic pregnancy, a life-threatening condition, occurs when a fertilized egg implants outside the uterine cavity. Early diagnosis and prompt intervention are crucial to prevent maternal morbidity and mortality. A comprehensive physical assessment plays a pivotal role in identifying and managing ectopic pregnancies.
History Taking
A thorough history should include:
- Menstrual history: Amenorrhea, irregular bleeding, or spotting
- Abdominal pain: Unilateral or bilateral, sharp or dull, constant or intermittent
- Vaginal bleeding: Scant or heavy, dark or bright red
- Risk factors: Previous ectopic pregnancy, pelvic inflammatory disease, assisted reproductive technologies
- Associated symptoms: Nausea, vomiting, diarrhea, shoulder pain
Physical Examination
General Examination
- Vital signs: Assess for tachycardia, hypotension, or fever
- General appearance: Note pallor, diaphoresis, or abdominal distension
Abdominal Examination
- Inspection: Look for distension, asymmetry, or masses
- Auscultation: Listen for bowel sounds and fetal heart tones
- Palpation: Perform a gentle bimanual examination to assess:
- Uterine size and consistency
- Adnexal tenderness or masses
- Cul-de-sac tenderness (indicating hemoperitoneum)
Pelvic Examination
- Speculum examination: Visualize the cervix for bleeding or discharge
- Bimanual examination: Palpate the uterus, ovaries, and adnexa to assess:
- Uterine enlargement or softening
- Cervical motion tenderness (indicating uterine irritation)
- Adnexal tenderness or masses
- Cul-de-sac fullness or bulging
Rectal Examination
- In selected cases: May be performed to assess for retroperitoneal hematoma or cul-de-sac tenderness
Additional Findings
- Shoulder pain (Kehr’s sign): May indicate diaphragmatic irritation due to hemoperitoneum
- Culdocentesis: A needle aspiration of the cul-de-sac may reveal blood or fluid
- Ultrasound: Transvaginal ultrasound is the primary imaging modality for diagnosing ectopic pregnancy.
Differential Diagnosis
Ectopic pregnancy must be differentiated from other conditions with similar symptoms, including:
- Threatened abortion
- Ruptured corpus luteum cyst
- Pelvic inflammatory disease
- Ovarian torsion
- Appendicitis
Management
Based on the physical assessment findings, the following management options may be considered:
- Medical management: Methotrexate or mifepristone may be used to terminate the ectopic pregnancy
- Surgical management: Laparoscopy or laparotomy may be necessary to remove the ectopic pregnancy and control bleeding
Complications
Untreated ectopic pregnancy can lead to:
- Tubal rupture: Life-threatening bleeding and hypovolemic shock
- Hemoperitoneum: Accumulation of blood in the peritoneal cavity
- Infection: Pelvic inflammatory disease or sepsis
- Infertility: Damage to the fallopian tubes
Conclusion
A comprehensive physical assessment is essential for the early diagnosis and management of ectopic pregnancy. By carefully assessing the patient’s history, performing a thorough physical examination, and considering differential diagnoses, healthcare providers can identify and treat this life-threatening condition promptly, reducing maternal morbidity and mortality.