Ectopic Pregnancy & Miscarriage

Unilateral pelvic pain with a positive pregnancy test and no intrauterine sac on ultrasound is an ectopic pregnancy until proven otherwise — delay costs a fallopian tube or a life.

An ectopic pregnancy implants outside the uterus, most commonly in the fallopian tube (~90–95%). The classic triad is missed period, unilateral lower abdominal or pelvic pain, and vaginal spotting. Serial quantitative hCG levels that fail to double every 48–72 hours raise suspicion; a transvaginal ultrasound showing no intrauterine gestational sac with hCG above the discriminatory zone (~1,500–2,000 mIU/mL) strongly suggests ectopic implantation. Rupture is the critical emergency — sudden severe unilateral pain, referred shoulder pain (from diaphragmatic irritation by blood), rigid abdomen, and signs of hemorrhagic shock (tachycardia, hypotension, falling hematocrit). Medical management uses methotrexate for unruptured cases; surgical intervention is required for rupture. Miscarriage (spontaneous abortion) is loss before 20 weeks. Types matter clinically: threatened (closed cervix, spotting, viable fetus), inevitable (dilated cervix, cramping), incomplete (partial tissue passage, open os), complete (all products expelled, cervix closed), and missed (fetal demise retained, no bleeding, closed cervix). Nursing priorities include monitoring blood loss, tracking serial hCG to zero, assessing for infection (fever, foul-smelling discharge), providing emotional support, and determining Rh status for possible RhoGAM administration.

Key Distinctions

Don't confuse ectopic pain (unilateral, sharp, often with referred shoulder pain) with placental abruption pain (constant, diffuse uterine rigidity in later pregnancy). Students mix up threatened versus inevitable miscarriage — the key is cervical os status: closed means threatened and potentially viable; open means inevitable. A missed miscarriage is silent — no active bleeding, but fetal cardiac activity is absent on ultrasound.

Clinical Pearl

Shoulder pain in early pregnancy with spotting screams ruptured ectopic — blood irritating the diaphragm refers pain to the shoulder via the phrenic nerve. Treat it as an emergency.