Common symptoms of EP include lower abdominal pain and vaginal bleeding; however, fewer than 50% of women presenting for evaluation have these classic symptoms, and in fact, these particular symptoms may be more indicative of a spontaneous abortion.14
Many of the symptoms of EP are similar to those of early pregnancy such as breast fullness, amenorrhea, nausea, vomiting, and fatigue. Therefore, a high index of suspicion is warranted in any female of childbearing age, especially in the setting of syncope, to evaluate pregnancy status and EP. The findings of a positive pregnancy test, abdominal pain, and vaginal bleeding have a positive likelihood ratio of 15% for having an EP.14
Abdominal fullness and abnormal uterine bleeding may be present as the uterus cannot sustain a stable endometrium in the setting of an EP.
Any female patient of reproductive potential presenting with abdominal symptoms must be asked about her last menstrual period (LMP) including timing, regularity, and characteristics of the menses, as well as prior pregnancies or complications, risk factors for EP, quality of the abdominal pain, vaginal bleeding or spotting, and syncopal episodes. Any referred pain to the shoulder or neck in the setting of a positive pregnancy test may indicate rupture, with blood causing diaphragmatic and phrenic nerve irritation with C3-C5 nerve root involvement. Additionally, patients may present with symptoms of nausea, vomiting, weakness, and dizziness. Abdominal pain can be alternating and spasmodic with pain-free periods.4
Regardless of whether a patient is using contraceptives or not, due to the potentially devastating effects of a missed or delayed diagnosis of EP, all sexually active women of reproductive age require a pregnancy test for any abdominal, vaginal, or urinary symptoms. Up to 40% of EPs have a delay in diagnosis beyond their initial presentation.14
Rare types of EP, such as interstitial pregnancy and cervical pregnancy, present later (8-10 weeks) and with catastrophic bleeding. Hence, it is prudent to check the pregnancy status of any female of reproductive potential beyond the common classically described symptoms.