a) Details of symptoms should be explored. This should focus on whether the onset of pain was before the start of bleeding or after the start of bleeding. If the pain started after the bleeding it is more likely due to ectopic and if pain started before the bleeding it is more likely miscarriage. The amount of blood loss is also important if it is heavy with blood clots it is suggestive of a miscarriage. Minimal port-wine coloured discharge would suggest ectopic pregnancy. Obstetric history is important to know the number of children and their mode of deliveries. Her desire of retaining fertility should also be ascertained. History of tubal damage and infertility should be determined. History of ovulation induction should also be obtained as it is also a risk factor for ectopic pregnancy.
Abdomen should be palpated to see if there is generalized tenderness or localized pain in one of the iliac fossa. With ectopic pregnancy the pain is more likely to localize in one fossa. Vaginal examination in case of ectopic pregnancy reveals closed cervix and tenderness in one iliac fossa. In case of threatened miscarriage the cervix is closed and in case of inevitable or incomplete miscarriage the cervix is open.
b) A full blood count should be done to check haemoglobin to ascertain if there is significant haemorrhage, and if the Hb is <9/g/dl she may need blood transfusion. The blood group should be determined and serum should be saved so that in case if she needs blood transfusion it can be transfused. Rhesus status should be determined so that if anti D is required it can be provided. The beta human chorionic gonadotrophin(HCG) concentration should be determined to aid in the diagnosis of ectopic pregnancy. Transvaginal ultrasound should be done as she has positive pregnancy test two weeks ago so an intrauterine or ectopic pregnancy is likely to be seen. She is advised to stay nil by mouth and I/V access should be obtained. Level of beta HCG and report of TVS will determine further management. If beta HCG is more than 1000 and pregnancy is not seen serum progesterone should be done to assess the risk for ectopic pregnancy. If it is >60, she is at high risk of ectopic pregnancy she should have a repeat scan as soon as possible or diagnostic laparoscopy should be planned. If beta HCG is <1000 and progesterone is >60, the risk of ectopic is low and an ultrasound should be repeated when HCG is more than1000. If HCG is less than 25 and progesterone is less than 25 she should be reassured and blood /urine should be repeated after one week. If progesterone is between 25 to 60 and HCG is >25 there is high risk of ectopic and she should have repeat bloods in 2 days.
c) Most ectopic pregnancies resolve spontaneously. Now their early diagnosis has resulted in over-treatment. Data from the management of pregnancies of unknown locations which were followed further shows that most of the abnormal pregnancies were ectopic, therefore if a pregnancy of unknown location is considered more likely to be ectopic ,it is justified to manage her expectantly. In case of known ectopic there is little justification of this management comparing its risks with high efficacy of methotrexate and surgical treatment. RCOG states it acceptable only if it involves little minimal risk to the women therefore if it is considered only in those cases which are selected very carefully, where woman is asymptomatic and has rapidly falling HCG levels.
