Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Updated: Aug 6 2021

Ectopic Pregnancy

Images sites.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
1 of 0
1 of 3
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options