7 Critical Causes of Ectopic Pregnancy Shoulder Pain

It is uncommon for any pregnant woman to have shoulder pain, but it is often unrelated to pregnancy. However, this is a cause for concern if ectopic pregnancy is related to it as it could mean bleeding within internal organs. In this post, we will figure out the ectopic pregnancy shoulder pain causes and what should be done.

Ectopic Pregnancy- What is it?

Around 1 in 80 pregnancies are ectopic. It occurs when fertilised egg implants outside the uterus. Outside of the uterus, the fertilised egg cannot survive. If allowed to grow, it can harm nearby organs and cause life-threatening blood loss.

Pelvic pain and vaginal bleeding are common symptoms while ectopic pregnancy shoulder pain should be seen by a team of doctors as early as possible. Treatment is required to avoid complications. Early stages can be managed with medications, however, later and more complicated stages require prompt surgery.

Features

Signs

Signs of an ectopic pregnancy include:

• Lower abdominal pain and tenderness (could be unilateral) “The first symptom”
• A missed period (recent amenorrhoea) = no menstruation for 6-8 weeks from the beginning of the last period
• Vaginal bleeding
• Shoulder tip pain “due to peritoneal bleeding” + Peritonism (Indicate ectopic tubal rupture)
• Cervical motion tenderness

Symptoms

The symptoms involve:

• Symptoms of mimic miscarriage, an upset stomach, or a urinary tract infection
• Unusual vaginal bleeding
• Pain in the abdomen
• Shoulder tip discomfort
• Problems with the bowel or bladder
• Period missed or late
• Positive pregnancy test results
• Vomiting or feeling nauseous
• Fainting or dizziness

Causes of Ectopic Pregnancy Shoulder Pain

Shoulder Tip Pain

Referred shoulder pain in pregnancy can occur due to the following reasons:

• Gallstones and related gallbladder infections
• Internal bleeding
• Heart attack or angina
• Polymyalgia rheumatica

Causes of Shoulder Pain in Ectopic Pregnancy

If you have been diagnosed with ectopic pregnancy and develop shoulder pain, it will warrant immediate attention and require a hospital ER visit. The list of causes of pregnancy pain in the shoulder is as follows (from most dangerous to least worrisome):

1. Internal Bleeding– This can occur when there is tubal pregnancy and the important cause of shoulder pain in an ectopic pregnancy (the most common type of ectopic pregnancy where the egg implants in the fallopian tube, and when the foetus grows, it can lead to rupture of the fallopian tube, causing peritonism- inflammation of the peritoneal cavity)
2. Rotator cuff tear
3. Frozen shoulder
4. Shoulder joint tear
5. Radicular pain
6. Shoulder injury
7. Sprain

Signs of Internal Bleeding

While ectopic pregnancy shoulder pain can mean internal bleeding, the other signs include:

Signs

• Extreme painful abdomen
• Non-passage of flatus or faeces
• On Abdominal Examination:
  • Tender and rigid abdomen
  • Absent bowel sounds

Symptoms

• Excruciating abdominal pain or tenderness
• Fullness in the abdomen
• Nausea and vomiting
• Loss of appetite
• Reduce urine with increased thirst
• Feeling light-headed or fainting
• Cold peripheries
• Chest or shoulder pain

Ruptured Ectopic Pregnancy

• Severe lower abdominal pain
• UPT +ve
• Tender iliac fossa pain
• USG shows Large-Moderate free fluid in Douglas pouch (also known as cul de sac)

• The fallopian tube is split open because of ectopic pregnancy

Risk factors

Ectopic pregnancy can occur due to several other reasons, the major risk factors are attributed as follows:

• PID (Pelvic Inflammatory Disease) e.g. chlamydia has a great risk for ectopic pregnancy (MAJOR)
• Endometriosis
• Assisted pregnancy
• Tubal ligation
• Previous ectopic pregnancy
• IUD- Intrauterine Device- Copper T (relative not absolute risk)

Investigations

Ectopic pregnancy shoulder pain requires prompt diagnosis and treatment modalities. Following the diagnostic algorithm for Ectopic pregnancy:

• UPT (Urine Pregnancy Test)
  • If +ve- TVS (Transvaginal Ultrasound- to look for intrauterine pregnancy)
    • If USG shows an empty uterus, then
      • If the patient is hemodynamically stable
        • Check beta-hCG
          • b-hCG<1400- Wait and observe (unlikely ectopic pregnancy). The foetus may be so small to be observed by USG
          • b-hCG>1400- Proceed to Laparoscopy (confirmed ectopic pregnancy)
  • • Important note: If hCG is not that high, and -repeat hCG after 48 hours first- is among the options, and the patient is stable, pick it. As it might be a tubal miscarriage that needs no Rx. If it is a tubal miscarriage, the hCG will be falling)

• If the patient is hemodynamically unstable (e.g. Hypotensive SBP <90)
  • Urgent Laparotomy (Open Salpingectomy or Salpingostomy)

Management

The management depends on the presentation, such as ectopic pregnancy shoulder pain warranting immediate steps. The following are the two approaches:

• Medical Mx- Methotrexate
  • Hemodynamically stable
  • No significant pain
  • Adnexal mass <35mm with no foetal heart visible
  • Serum hCG<5000 IU/ltr (ideally <1500/ltr)
• • Surgical Mx
    • Hemodynamically unstable (Laparotomy)
    • Significant pain
    • Ruptured ectopic
    • Cannot come for follow up
    • Visible heartbeat

• Important
  • Laparoscopic Salpingectomy is preferred if the patient is hemodynamically stable but with other signs mentioned above

Conclusion

Pregnancy is a delicate event which requires care and supervision. While pain in the shoulder in ectopic pregnancy is an issue that should be handled swiftly, there are other causes for it too.

However, anyone experiencing it should not turn a blind eye to it and be careless. It could mean a potentially life-threatening event. You can find a complete list of symptoms at the NHS portal here.