Examination

The diverse presentation of women eventually diagnosed with EP means a safe and rational approach to each is required. In the ‘un­well' patient, key factors of the history will be taken alongside the examination while resuscitation begins.

For the unwell woman with haemodynamic compromise and a positive pregnancy test, the approach should take the form of an ‘arrest call'. Airway, breathing, and circulation (ABC) should be assessed and help rapidly summoned to assist with resuscitation. In the case of a women presenting in extremis, the diagnosis can be assumed to be ruptured EP with significant haemoperitoneum. The patient requires urgent intravascular volume resuscitation and immediate transfer to theatre for laparoscopy or laparotomy.

The majority of patients present in good condition allowing time for a more detailed assessment. The ABC approach should still be used. Women at an early stage of blood loss from a bleeding EP may have a higher than normal respiratory rate. As blood loss continues, the measures taken by the cardiovascular system to compensate for this can be detect by straightforward observation of blood pressure (BP), heart rate, and respiratory rate. The loss of intravascular volume caused by bleeding in the case of EP first results in an increase in ar­terial vascular tone to maintain blood pressure. This change can be de­tected by performing erect and supine blood pressure measurements (10). The normal response in BP when changing position from sitting to standing is for a rise in the systolic BP resultant from the increased vascular tone. This rise in BP is lost when the arteries are maximally constricted in the supine position and is an early sign of intravascular depletion. This is usually associated with a mild increase in respiratory rate. Ongoing blood loss will then be additionally compensated for by an increase in heart rate to maintain cardiac output.

If the blood loss is ongoing, these mechanisms can no longer maintain BP and the woman becomes hypotensive. The respiratory rate will be high. This matches the description of the ‘unwell woman' described previously and demands immediate action. At this stage she will have lost around 40% of her circulating blood volume into her peritoneal cavity. Urgent attention is warranted as this is a life­threatening amount of blood loss. The likelihood is that the EP has concealed the loss of at least 2 L of blood, and at this stage consump­tion of clotting factors is likely to result in coagulation dysfunction, further compounding the rate of blood loss. The concealed nature of the blood loss can mean appropriate measures are delayed, and care providers are falsely reassured. Formal assessment of the ABC will guide the extent of physiological compromise and balance the urgency and nature of the response.

The ‘end- of-the-bed' look at the woman can be revealing about the amount of pain being experienced and if there is pallor. A normal radial pulse and capillary refill under 2 seconds at the fingertips is a reassuring finding. The abdomen may be distended and previous surgical scars noted on inspection. Palpation may reveal guarding or rebound tenderness.

A speculum should be used to examine the lower genital tract and the cervix, particularly so with concurrent symptoms of va­ginal bleeding. A cervix open and distended with products of con­ception is indicative of an inevitable miscarriage (see Chapter 38) and can cause abdominal pain, vaginal bleeding, and hypotension with bradycardia rather than tachycardia (vagal shock). Removing the tissue distending the cervix will stop the stimulation of the vagal nerve causing the cardiovascular depression, quickly relieve the pain, and reverse the bradycardia.

Bimanual examination (see Chapter 1) gives an opportunity to assess for ‘cervical excitation'. This is analogous to testing for re­bound tenderness during abdominal examination. Gentle rocking of the cervix from side to side causes the pelvic peritoneum to be alternately stretched and relaxed. Movement of inflamed or tethered peritoneum will be experienced as pain and in this context is sug­gestive of an EP. This finding is typically absent in a normal intra­uterine pregnancy. The size of the uterus and the presence of adnexal masses or tenderness can be assessed.

A urinary pregnancy test is usually performed at some point. These are sensitive and accurate with a positive result generated at a cor­responding serum concentration of human chorionic gonadotropin (hCG) of 25 IU/L. A false-negative result is occasionally obtained by testing a dilute sample of urine, or reading the result before allowing enough time for the test result to develop. A false-positive result can be produced by cross reaction with other metabolites or toxins, oc­casionally seen with sepsis (11). For these reasons, and mostly for the interpretation of the following investigations, a serum quanti­tative hCG should be taken alongside urine hCG testing and other blood tests detailed in the following sections.