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Updated: Aug 6 2021

Ectopic Pregnancy

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  • 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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