There is no one classical presentation of EPL; it commonly occurs without symptoms or with one or more of the following:

  • Vaginal bleeding (the 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.

Evaluation should include a physical examination, US, and / or quantitative hCGs. Serial hCGs are most helpful when US is inconclusive (i.e. pregnancy of unknown location), and are unnecessary after US confirms an intrauterine EPL.

Physical exam assesses patient’s status and offers diagnostic clues; it should include:

  • Vital signs +/- labs (including orthostatics and H/H if symptoms of hypovolemia or anemia or with heavy bleeding)
  • Abdominal examination (to rule out peritonitis or other causes for symptoms)
  • Pelvic examination (for bleeding, cervical dilatation, tenderness)
  • Tissue examination (for clot vs. pregnancy tissue)
EPL diagnosis is suggested by clinical history with rapidly declining hCGs in absence of IUP on US.
EPL diagnosis is confirmed by one of the following:

  1. US confirmation of anembryonic gestation or embryonic/fetal demise in the uterus
  2. Absence of previously seen IUP on US
  3. Tissue exam confirming membranes and villi expelled or removed from uterus.

In all patients presenting with first trimester bleeding, ectopic pregnancy should be considered. Ectopic pregnancies often present with vaginal spotting, frequently occurring at 6-8 weeks gestation. Due to the implantation of an ectopic pregnancy at sites ill-equipped to support the nourishment of a growing pregnancy, levels of hCG can be insufficient to support the corpus luteum, eventually causing sloughing of the endometrial lining. In the interim, levels of hCG can rise or fall. In addition to vaginal bleeding, other signs and symptoms of ectopic pregnancy include abdominal pain and/or rebound tenderness, referred shoulder pain, and syncope.

Remember two critical aspects of the evaluation in a patient with signs or symptoms of EPL:


  • Ensure hemodynamic stability, and manage or refer as appropriate
  • Evaluate for ectopic pregnancy, and treat or refer as appropriate


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