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https://upload.medbullets.com/topic/111073/images/ectopic_pregnancy.jpg
Snapshot
  • A 24-year-old woman presents to the ED with 6 hours of severe left lower quadrant abdominal pain and some moderate vaginal bleeding. She is sexually active with 1 male partner and uses condoms occasionally. She has a history of pelvic inflammatory disease. Her last period was 7 weeks ago. A transvaginal ultrasound is performed and shows a mass in the left adnexa.
Introduction
  • Overview
    • ectopic pregnancy is any pregnancy outside the uterine cavity
    • ruptured ectopic is when the structure containing the pregnancy (such as fallopian tube) ruptures
    • second leading cause of maternal mortality
  • Epidemiology
    • incidence
      • 6-16% among women who present to ED with vaginal bleeding and/or pain
      • estimated overall incidence 0.28-2.1% of pregnancies in U.S.
    • location
      • most commonly found in the fallopian tubes (96%)
        • ampulla (75%)
        • isthmus (12%)
      • other sites
        • abdomen
        • hysterotomy scar (embedded in cesarean scar)
        • cervix
    • risk factors
      • prior ectopic pregnancy
      • pelvic inflammatory disease (PID) 
      • intrauterine device (IUD) use
        • low risk of any pregnancy, but if pregnancy occurs then higher risk of ectopic than women not using IUD
      • prior tubal surgery
      • advanced maternal age
  • Pathogenesis
    • implantation of fertilized egg outside of the uterine cavity
  • Prognosis
    • life-threatening, if ruptured
    • pregnancy is non-viable
Presentation
  • History
    • woman of reproductive age
    • patient is sexually active
    • missed recent period
  • Symptoms
    • usually present in first trimester
      • 6-8 weeks after last normal menstrual period
    • abdominal/pelvic pain
      • may be sudden onset or slow onset
      • no one typical type of pain: may be constant/intermittent, sharp/dull, and mild – severe
      • referred shoulder pain may be present if rupture with sufficient blood to irritate diaphragm
    • vaginal bleeding or spotting
    • amenorrhea
    • other symptoms of pregnancy
      • breast tenderness
      • frequent urination
      • nausea
    • temperature > 38°C is unusual (look for infectious cause)
    • may be asymptomatic
  • Physical exam
    • cervical motion tenderness
    • adnexal mass
    • blood in vaginal canal
    • ruptured ectopic pregnancy may present with
      • hypotension
      • signs of shock
      • acute abdomen
Imaging
  • Transvaginal ultrasound 
  • indications
    • elevated β-hCG with no signs of uterine gestational sac on ultrasound is highly suspicious for ectopic 
    • assess for site of gestational sac with a yolk sac or embryo
    • measuring the size will guide treatment
  • findings 
    • peritoneal free fluid if ruptured
    • if no mass visualized inside or outside uterus
      • rely on serum β-hCG quantification (≥ 1500 mIU/mL or failure to double after 48 hours) to determine if ectopic
    • "snowstorm" appearance of uterus indicates molar pregnancy
Studies
  • Labs 
    • urine pregnancy test: positive
    • serum β-hCG
      • ≥ 1500 mIU/mL indicates ectopic pregnancy
      • if < 1500 mIU/mL, repeat test in 48 hours 
      • in ectopic pregnancy β-hCG does not increase at an appropriate rate 
        • β-hCG level will be less than double after 48-72 hours
        • intrauterine pregnancy: β-hCG will double after 48-72 hours
    • Rh(D) typing and antibody screen
Differential
  • Ruptured ovarian cyst 
    • negative β-hCG (unless ruptures during pregnancy)
    • vaginal bleeding not usually associated
    • pelvic ultrasound
      • may see thin wall of previous cyst
      • may see free fluid (also in ruptured ectopic)
  • Molar pregnancy 
    • will see “snowstorm” appearance of uterus on ultrasound
    • β-hCG may be much higher than in typical pregnancy or ectopic
  • Spontaneous abortion
    • intra-uterine pregnancy may be visualized on ultrasound
    • cervical os may be open on pelvic exam
    • may have passage of fetal contents from vagina
    • β-hCG will decrease on 48-hour repeat test
Treatment
  • Medical
    • methotrexate
      • contraindicated if patient currently breastfeeding
    • must meet the following criteria
      • β-hCG ≤ 5000 mIU/mL
      • gestational sac < 3.5 cm
      • no fetal heart tone
    • RhoGAM (anti-D immune globulin)
      • give to all Rh(D)-negative mothers to prevent antibody formation 
  • Surgical 
    • laparoscopic salpingostomy  
      • if does not meet criteria for medical management
      • no signs of rupture
    • laparoscopic salpingectomy
      • if evidence of rupture
        • free fluid in pelvic cavity
        • signs of shock
  • Follow up post-treatment β-hCG levels to ensure complete destruction of trophoblastic tissue
Complications
  • Recurrent ectopic pregnancy
    • incidence
      • approximately 15%
    • due to anatomic and functional changes in fallopian tubes secondary to clinical or subclinical salpignitis 
  • Infertility
    • incidence
      • 11-62%
    • risk factors
      • prior history infertility
        • pregnancy rate following ectopic pregnancy in women with history of infertility is one-fourth that of women without known infertility prior to ectopic
      • decreased risk if ectopic occured during IUD use
  • Death
    • incidence
      • approximately 31.9 per 100,000 pregnancies
    • risk factors
      • ruptured ectopic pregnancy
        • severe hemorrhage from intraperitoneal bleeding
 

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