Emergency Medicine Myths: Ectopic Pregnancy Evaluation, Risk Factors, and Presentation

Ectopic pregnancy (EP) is an important cause of morbidity and mortality in females of reproductive age. Proper diagnosis and treatment are critical, as complications such as rupture, hemorrhagic shock, and even death can occur. EP is a condition emergency physicians are trained to detect, yet there are multiple myths concerning its evaluation and diagnosis. This article reviews several of these myths in order to improve emergency department (ED) evaluation and diagnosis. EP is a difficult diagnosis and may be missed on initial ED visit. While the diagnosis is often delayed simply due to very early presentations, it can also be missed because patients may not have all the same risk factors or demonstrate the same symptoms. They may also not demonstrate the same serum B-human chorionic gonadotropin levels and trends or have the same ultrasound findings at equivalent gestational ages. Some patients with early EP may have positive ultrasound findings with serum β-hCG levels under a defined discriminatory zone (DZ). On the other hand, some patients with an early viable intrauterine pregnancy may have no visible findings on initial ultrasound, but have serum β-hCG (quantitative) levels well above the DZ. Although rare, EP has even been demonstrated in women with negative urine β-hCG tests or low serum β-hCG levels. While EP may be a challenging diagnosis, understanding the myths surrounding EP may help emergency physicians consider it, even when patient risk factors, symptoms, or ED laboratory or imaging studies do not initially or easily define the diagnosis.