EPL DIAGNOSTIC AND CLINICAL CONSIDERATIONS

EPL presentation varies but commonly occurs without symptoms or with one or more of the following:

• Vaginal bleeding (most common sign)
• Abdominal cramping, pelvic or back pain
• Passing of tissue from the vagina
• Loss of pregnancy related symptoms (breast tenderness, nausea)
• Constitutional symptoms such as fever or malaise

Although vaginal bleeding is the most common sign, it does not always signify EPL:

• 30% of pregnancies that progress to term have vaginal bleeding.
• 50% ongoing pregnancy rate with isolated bleeding and closed cervix.
• 85% ongoing pregnancy rate with confirmation of fetal cardiac activity (Bae 2011).

Evaluation should include: history, physical exam, US, and/or quantitative hCGs.

• Physical exam assesses clinical status and offers diagnostic clues; it should include:
  • Vital signs (including orthostatics)
  • Labs as needed:
    • H/H if symptoms/clinical findings of hypovolemia, anemia or heavy bleeding
    • Rh testing not needed for EPL < 12 weeks (ACOG 2024)
  • Abdominal examination (to rule out peritonitis or other causes for symptoms such as GI or urologic etiologies)
  • Speculum exam: for bleeding including non-uterine sources, cervicitis
  • Bimanual exam: for cervical dilatation, tenderness
  • Tissue exam, if present: for clot vs. pregnancy tissue
  • US identifies features diagnostic or suggestive of EPL, and may show a bleeding source (i.e. subchorionic hematoma (SCH); See Ch 3: Subchorionic Hematoma). While greater size of SCH and persistence > 12 weeks are correlated with higher risk of EPL, a complete evaluation is needed (Qin 2022, Yan 2023, Liang 2024).
• Serial hCGs are most helpful when the US is inconclusive (i.e. whether the diagnosis is a PUL or completed EPL; see Ch. 3: PUL (hCG trends).

Ectopic pregnancy should be considered in the differential diagnosis in anyone presenting with a positive pregnancy test and vaginal bleeding without a confirmed IUP. Ectopic pregnancies often present with vaginal spotting at 6-8 weeks gestation. Implantation of an ectopic pregnancy at sites ill-equipped to support a pregnancy (including cesarean scar in addition to fallopian tubes and other locations) causes hCG levels to be insufficient to support the corpus luteum, with subsequent sloughing of the endometrial lining. In the interim, hCG levels can rise or fall. Other signs and symptoms of ectopic pregnancy include abdominal pain and/or rebound tenderness, referred shoulder pain, and syncope. See Chapter 3: PUL.