Clinical presentation

There is a wide spectrum of clinical presentation in women with EP, ranging from asymptomatic and subacute to collapse with circula­tory arrest. Symptoms of EP also overlap with other common con­ditions, again emphasizing the importance of pregnancy testing in women of reproductive age.

Abdominal pain, vaginal bleeding, or a combination of both, in early pregnancy are common presentations in women with EP. There is considerable overlap of symptoms in women with viable pregnan­cies and miscarriage. The cause of vaginal bleeding may also be from the lower genital tract, as a result of trauma, infection, a cervical polyp, or rarely malignancy. Abdominal pain may result from the presence or torsion of ovarian cysts. Pain may also be entirely non- gynaecological such as constipation, gastroenteritis, irritable bowel syndrome, cystitis, renal colic, or appendicitis.

EPs can result in intraperitoneal bleeding, often associated with rupture of the fallopian tube. The rate of bleeding may be modest; however, changes resultant from the implantation mean that the bleeding is unlikely to stop spontaneously, resulting in a haemoperitoneum. The symptoms associated with this are related to the size of the haemoperitoneum, hypovolaemia, and referred pain. The woman may report abdominal distention with pain, dizziness, and pain at the shoulder tip. The shoulder tip pain is referred pain caused by the extravascular blood in the peritoneum irritating the diaphragm and the phrenic nerve.

There are many established risk factors for EP. Many are related to fallopian tube dysfunction and include smoking, pelvic inflamma­tory disease, past or present infection with Chlamydia trachomatis, endometriosis, previous pelvic surgery (such as appendicectomy, caesarean section, or surgical female sterilization), and previous his­tory of EP (1, 4, 5). A woman with a positive pregnancy test after sterilization has a higher risk of having an EP compared to a non­sterilized woman.

An important risk factor for EP is a history of previous EP, with around a 15% recurrence rate after one previous EP. The reasons for this are a combination of ongoing risk factors for cumulative tubal dysfunction, and the mode of treatment for the previous EP (7).

Assisted reproductive technology, particularly in vitro fertiliza­tion with embryo transfer (IVF-ET), is associated with a higher risk of EP (see Chapter 52). The reasons for this may relate to the under­lying reasons necessitating IVF-ET as this technique bypasses the fallopian tube, and also to the techniques involved (8).

When assessing a woman with a possible EP, it is important to enquire about the woman's fertility intent in a sensitive manner. Ascertaining this from the outset will guide any discussion and con­sent process, particularly with treatments for EP that can affect fu­ture fertility.