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Updated: Aug 19 2021

Ectopic Pregnancy

  • 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
    • 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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