Elements of the history that increase the risk for EP are absent in nearly 50 percent of cases and are therefore useful only in increasing clinical suspicion in equivocal cases. The menstrual history is often abnormal, with amenorrhea of between 4 and 12 weeks reported in approximately 70 percent of cases. No missed menses are reported in approximately 15 percent of cases; thus neither a normal menstrual history nor prolonged amenorrhea has a sufficient negative predictive value to rule out an EP.2

Abdominal pain is expected in EP with tubal rupture but may be absent without rupture. Overall, up to 10 percent of ED patients with EP may not report pain. The classic pain of rupture is lateralized, sudden, sharp, and severe. However, many atypical pain patterns occur. A ruptured EP may present with shoulder pain from referred diaphragmatic irritation. This was reported in up to 20 percent of patients in one study. Pain may be absent even with rupture, as 4 percent of women in one study with hemoperitoneum from ruptured EP did not report pain. When nonruptured EP is painful, the pain is presumably from tubal distention. With the goal of early diagnosis, the absence of pain is not sufficient to exclude EP from consideration in a patient with other signs or symptoms of the disorder. 2

Vaginal bleeding is noted in up to 80 percent of cases of EP. Bleeding is usually scanty, but other patterns may occur. Classically, light bleeding occurs at or about the time of expected menses and may be mistaken for a normal period. Bleeding usually precedes pain. The duration of bleeding ranges from 1 day to several months before diagnosis. Heavy bleeding should increase suspicion for threatened abortion or another complication of an intrauterine pregnancy but does not rule out an EP. Typical early pregnancy symptoms may occur and may not differ from symptoms of previous normal intrauterine pregnancies.2

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