Bleeding from an ectopic pregnancy (EP) causes 10% of all pregnancy-related deaths and is the leading cause of maternal death in the first trimester. It also carries a high risk of future health complications. Despite what is known about the risks, ectopic pregnancies are often misdiagnosed by healthcare providers.
What is an Ectopic Pregnancy?
An EP occurs when an embryo implants outside of the uterine cavity. The most common site of ectopic implantation is the fallopian tube. Implantation can also occur in the cervix, ovaries, abdominal cavity, or within a prior cesarean section scar.
In the general population, one or two out of every 100 pregnancies will be ectopic. The occurrence rises to two-five EPs out of every 100 for patients undergoing assisted reproduction.
Other factors that increase the likelihood of having an EP include:
- Prior ectopic pregnancies.
- A history of fallopian tube surgery or tubal ligation.
- Advanced maternal age.
- A history of pelvic infections.
- Intrauterine device (IUD) use.
Treatment of Ectopic Pregnancy
Ectopic pregnancies are not considered viable. There is no way for a fertilized egg to grow fully outside of the uterus. Currently, there is no technology available to move an ectopic embryo to the uterus. The standard treatments for EP are either medicine or surgery.
Methotrexate: an injection is used to stop the fertilized egg’s cells from growing. The body reabsorbs any cells that have already developed. The benefit of this treatment is that it should not damage the fallopian tube.
Surgery: a surgeon makes a small cut, inserts a camera, and removes the embryo. There is a risk that surgery may cause scarring or that a piece of the fallopian tube will need to be removed along with the embryo.
The Risks of EP
The importance of timely identification and treatment can’t be overstated. There are significant risks of mortality and morbidity associated with EP that early detection may prevent.
Between 6% to 16% of pregnant women who go to an emergency department in the first trimester for bleeding, pain, or both have an ectopic pregnancy.
Some of the risks of missing this common diagnosis include: hemorrhaging, infertility, higher risk for future ectopic pregnancy, need for surgery and emotional pain and suffering.
All patients with a suspected EP should be considered potentially hemodynamically unstable.
Standards for Preventing a Missed EP
Reports estimate that 40% of ectopic pregnancies go undiagnosed at first presentation. It is considered a challenging condition to identify, even among experienced gynecologists.
A history and physical exam alone is unlikely to be sufficient to diagnose an EP. Other conditions with similar presentations include urinary tract infection, appendicitis, miscarriage, early pregnancy, pelvic infection, or ovarian cysts. Providers may not even consider it as part of the differential diagnosis.
How to Minimize the risk of missing an EP
Female patients of childbearing age who have not undergone a hysterectomy should receive a pregnancy test, including patients with a tubal ligation or who say they could not be pregnant.
Serum pregnancy tests are more accurate than urine tests, especially when the patient has been consuming a lot of fluids.
The chart should document why an ectopic pregnancy is ruled out, with risk factors addressed.
Any discrepancy between symptoms in the nursing notes and the physician’s notes should be reconciled.
Perform serial exams for any patient with unexplained abdominal pain.
Sending a patient with a possible ectopic pregnancy home from the hospital isn’t a definite deviation from the standard of care, but it can be risky. A negative ultrasound that does not identify an intrauterine pregnancy doesn’t rule out the possibility of an EP.
Providers should ensure adequate follow up as a way to minimize this risk. Ideally, patients with a pregnancy of an undetermined location should be seen by an obstetrician within 48 hours for a repeat exam, labs, and ultrasound.
The provider should tell the patient if a workup can’t definitively rule out an ectopic pregnancy. Besides being good practice, clear communication can be legally protective. If the patient later finds out that she has an ectopic pregnancy, recalling that the provider had said this could make them less likely to follow up with a malpractice suit.