With the availability of early pregnancy testing, the ability to diagnose ectopic pregnancy before rupture—even before the onset of symptoms—is not unusual. The classic symp-toms associated with ectopic pregnancy are amenorrhea followed by vaginal bleeding and abdominal pain on the affected side. However, there is no constellation of symp-toms that are diagnostic. Other pregnancy discomforts, such as breast tenderness, nausea, and urinary frequency, may accompany more ominous findings. These include shoul-der pain worsened by inspiration, which is caused by phrenic nerve irritation from subdiaphragmatic blood, or vaso-motor disturbances such as vertigo and syncope from hem-orrhagic hypovolemia.
As long as placental hormones are produced, there is usually no vaginal bleeding. Irregular vaginal bleeding re-sults from the sloughing of the decidua from the endome-trial lining. Vaginal bleeding in patients with an ectopic gestation may range from little or none to heavy, menstrual-like flow. In some patients, the entire “decidual cast” is passed intact, simulating a spontaneous abortion. Histo-logic evaluation of this tissue confirms whether placental villi are present. In any patient with a positive pregnancy test result, whenever evaluation of tissue passed sponta-neously or obtained by curettage does not demonstrate villi, an ectopic implantation should be assumed to be pre-sent until proven otherwise.
Many women with a small unruptured ectopic preg-nancy may have unremarkable clinical findings. Neverthe-less, the diagnosis should be considered strongly when any of the above symptoms are reported by reproductive-age women, especially those with risk factors for an extrauter-ine pregnancy.