Updated: 8/19/2021

Ectopic Pregnancy

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  • Snapshot
    • A 24-year-old woman presents to the emergency room 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 the emergency department with vaginal bleeding and/or pain
      • estimated overall incidence 0.28-2.1% of pregnancies in United States
    • 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
        • although women with an IUD have a very low risk of becoming pregnant, if they do get pregnant then they have a higher risk of ectopic pregnancy than pregnant women without an IUD
      • prior tubal surgery
      • advanced maternal age
  • ETIOLOGY
    • Pathogenesis
      • Implantation of fertilized egg outside of the uterine cavity
  • 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, mild to 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 (100.4°F) 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
      • key distinguishing factors
        • 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
      • key distinguishing factors
        • β-hCG may be much higher than in typical pregnancy or ectopic
        • pelvic ultrasound
          • “snowstorm” appearance of uterus
    • Spontaneous abortion
      • key distinguishing factors
        • β-hCG will decrease on 48-hour repeat test
        • physical exam
          • cervical os may be open on pelvic exam
          • may have passage of fetal contents from vagina
        • pelvic ultrasound
          • may visualize intra-uterine pregnancy may be visualized on ultrasound
  • Treatment
    • Management approach
      • follow up post-treatment β-hCG levels to ensure complete destruction of trophoblastic tissue
    • Medical
      • methotrexate
        • indications
          • β-hCG ≤ 5000 mIU/mL
          • gestational sac < 3.5 cm
          • no fetal heart tone
        • contraindications
          • patient currently breastfeeding
      • RhoGAM (anti-D immune globulin)
        • indications
          • all Rh(D)-negative mothers
          • given to prevent antibody formation
    • Surgical
      • laparoscopic salpingostomy
        • indications
          • patient does not meet criteria for medical management
          • no signs of rupture
      • laparoscopic salpingectomy
        • indications
          • evidence of rupture
            • free fluid in pelvic cavity
            • signs of shock including hemodynamic instability
  • 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 1/4 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
  • Prognosis
    • Life-threatening if rupture
    • Pregnancy is non-viable

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(M2.OB.14.80) A 32-year-old woman presents to the emergency department with abdominal pain. She states it started last night and has been getting worse during this time frame. She states she is otherwise healthy, does not use drugs, and has never had sexual intercourse. Her temperature is 99.0°F (37.2°C), blood pressure is 120/83 mmHg, pulse is 85/min, respirations are 12/min, and oxygen saturation is 98% on room air. A rectal exam is performed and the patient is subsequently disimpacted. Five kilograms of stool are removed from the patient and she subsequently states her symptoms have resolved. Initial laboratory tests are ordered as seen below.

Urine:
Color: Yellow
Protein: Negative
Red blood cells: Negative
hCG: Positive

A serum hCG is 1,000 mIU/mL. A transvaginal ultrasound does not demonstrate a gestational sac within the uterus. Which of the following is the best next step in management?

QID: 106950
1

Laparoscopy

0%

(0/79)

2

Methotrexate

6%

(5/79)

3

Salpingectomy

6%

(5/79)

4

Salpingostomy

48%

(38/79)

5

Ultrasound and serum hCG in 48 hours

38%

(30/79)

M 7 E

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