🩸 Ectopic & Molar Pregnancy
Early pregnancy bleeding sorted by where the pregnancy is. Shoulder pain means rupture; very high hCG means a mole.
🧬 Ectopic pregnancy
A fertilised ovum implants outside the uterus — about 90% in a fallopian tube. The tube cannot stretch, so it eventually ruptures.
This is the leading cause of maternal death in the first trimester.
| Sign | Detail |
|---|---|
| Classic triad | Missed period + unilateral stabbing pain + spotting |
| Shoulder pain | Rupture — blood in the abdomen irritates the diaphragm and refers to the shoulder |
| hCG | Rises more slowly than in a normal pregnancy |
| Shock | Tachycardia then hypotension; often more bleeding than is visible |
Shoulder pain in early pregnancy is a ruptured ectopic until proven otherwise. It is a surgical emergency.
Risk factors: previous ectopic, PID or salpingitis, tubal surgery, endometriosis, IUD in place, smoking.
🩺 Care
- Unruptured — may be treated with methotrexate. Teach: avoid folic acid supplements and alcohol, and no intercourse until hCG is undetectable
- Ruptured — two large-bore IVs, type and crossmatch, oxygen, straight to theater
- RhoGAM if Rh negative
- Acknowledge the loss — this is a pregnancy loss as well as an emergency
🍇 Hydatidiform mole
Abnormal placental tissue grows instead of a fetus — grape-like vesicles filling the uterus.
| Sign | Detail |
|---|---|
| hCG | Extremely high — far above expected for dates |
| Uterus | Larger than dates |
| Bleeding | Dark brown “prune juice”, may pass grape-like vesicles |
| Fetal heart | Absent; no fetus on ultrasound |
| Other | Severe nausea and vomiting; preeclampsia before 20 weeks |
Preeclampsia before 20 weeks is not normal preeclampsia — it points to a molar pregnancy. That detail is asked directly.
🩺 After evacuation
- Serial hCG levels for a full year — they must fall to zero and stay there
- Reliable contraception for that year
She must not become pregnant for a year. A rising hCG is the marker for choriocarcinoma - and a new pregnancy would raise hCG and hide it.
Molar pregnancy carries a real risk of choriocarcinoma, which is why the follow-up is so strict.
🎯 NCLEX traps
- Shoulder pain = ruptured ectopic
- Very high hCG + uterus large for dates + no fetal heart = mole
- No pregnancy for one year after a mole, with monthly hCG
- Preeclampsia before 20 weeks suggests a mole
- RhoGAM after any early pregnancy loss if Rh negative