All acute abdomens in gynaecology should be treated as an ectopic pregnancy until proven otherwise.
Positive pregnancy test
Ruptured ectopic pregnancy is classically one of the two conditions in which definitive operative management should not be delayed for resuscitation (along with ruptured abdominal aortic aneurysm).
A woman with a positive pregnancy test, an acute abdomen and signs of haemodynamic compromise should be transferred immediately to theatre for surgical intervention. In some cases it may be necessary to transfer patients to theatre prior to a positive pregnancy test.
Ectopic pregnancy is a potential cause of maternal mortality, being a direct cause of nine maternal deaths in the most recent MBRRACE report, (2012-2014).
Despite modern advances, the diagnosis of ectopic pregnancy can still be difficult and challenging. β-hCG does not rise by ≥66% in 15% of healthy intrauterine pregnancies, whilst 13% of all ectopic pregnancies have a normally rising β-hCG.
A negative pregnancy test normally excludes a 'clinically significant' ectopic pregnancy; however, a negative urine and serum β-hCG tests have been reported among 3.1% and 2.6% of ectopic pregnancies respectively.
Also, it has been reported that 8% of patients with negative (false-negative) urinary pregnancy tests subsequently required surgery. Therefore, it is important to maintain a high index of suspicion of its diagnosis even with negative pregnancy test and take a thorough history and perform a comprehensive clinical examination supported by proper investigations especially in atypical presentation.
A catheter urine specimen should be obtained without delay if a woman is unwell and cannot pass urine.