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Ectopic Pregnancy
Aka: Ectopic Pregnancy, Tubal Pregnancy
See AlsoFirst Trimester Bleeding Methotrexate Ectopic Protocol
EpidemiologyIncidence : 2% of all pregnanciesSecond most common cause of maternal mortalityAccounts for 6% of maternal deaths (as high as 10-15% of maternal deaths in past) Case fatality rate: 3.8 deaths per 10,000 ectopics
Risk FactorsHighest risk factorsPelvic or tubal surgery (e.g. Tubal Ligation ) Prior Ectopic Pregnancy (11% of cases) Intrauterine Device (IUD) (14% of cases)Diethylstilbestrol Exposure in utero (DES Exposure ) Moderate risk factorsPelvic Inflammatory Disease or other tubal infectionInfertility (15% of cases)Multiple sexual partners Other risk factorsEndometriosis Mini Pill use (Progestin only pill) Tobacco abuseVaginal Douching Early age at first intercourse (age <18 years)
SymptomsOnset occurs ~7 weeks after last menstrual period Abdominal Pain Vaginal Bleeding
SignsPrecaution: Exam can not exclude Ectopic PregnancyNo Vaginal Bleeding in 30% of ectopic pregnancies Negative pelvic exam in 10% of ectopic pregnancies Buckley (1999) Ann Emerg Med 34:589-94 Ectopic chance if Abdominal Pain and Vaginal Bleeding No risk factors: 39% Risk factors: 54% Mol (1999) Hum Reprod 14:2855-62 Classic (15% of patients)Pelvic Pain or Abdominal Pain (97%)Initially localized pain Pain later generalizes Abdominal tenderness (91%) First Trimester Bleeding (79%) Common associated findingsAdnexa l tenderness (54%)Amenorrhea Shoulder Pain BR signPatient faints post Bowel Movement Early Pregnancy Symptoms Cullen's Sign (Periumbilical bruising)Nausea or Vomiting Diarrhea Dizziness Ectopic Pregnancy ruptures between 6 and 12 weeks Other SignsOrthostasis Tachycardia Low grade fever Chadwick's Sign (Cervix and vaginal cyanosis)Hegar's Sign (softened uterine isthmus)Hypoactive bowel sounds Cervical Motion Tenderness Enlarged Uterus Tender pelvic or Adnexal Mass Cul-de-sac fullness Decidua l cast (Passage of Decidua in one piece) Signs suggestive of ruptured Ectopic PregnancySevere abdominal tenderness with rebound, gaurding Orthostatic Hypotension
Differential DiagnosisMost common alternative diagnosesAppendicitis Threatened Abortion Ruptured Ovarian Cyst (corpus luteum) Pelvic Inflammatory Disease Salpingitis Endometritis Nephrolithiasis Ovarian torsion Intrauterine Pregnancy Other alternative diagnosesHeterotropic pregnancy Dysmenorrhea Dysfunctional Uterine Bleeding Urinary Tract Infection Diverticulitis Mesenteric lymphadenitis
LabsSee Imaging below Quantitative hCG Normally will increase by at least 53% every 2 daysUsually will double in 48 hours bHCG with inadequately increase may suggest ectopicTest Sensitivity : 36%Test Specificity : 65% bHCG level does not predict ruptured ectopicRuptured ectopic may occur at any bHCG level Blood Type and Rh, hold units Complete Blood Count Leukocytosis Urinalysis with microscopic examCuldocentesisRarely performed now due to Transvaginal Ultrasound Differentiates ruptured Ovarian Cyst from ectopic Yield of aspirate with >15% Hematocrit suggests bleed Tests not recommended for ectopic diagnosisSerum Progesterone (Test Sensitivity : 15%)
ImagingGeneralFindings suggestive of intrauterine pregnancyIntrauterine Gestational Sac suggests intrauterine pregnancy (Yolk Sac confirms it)Central blastocyst Surrounding double ring of echogenic Decidua and chorionic villi ExceptionsPseudogestational sac (no true Gestational Sac )No Echogenic ring No Yolk Sac or fetal pole seen Heterotopic pregnancy (rare: 1 in 4000 risk)Simultaneous intrauterine and Ectopic Pregnancy Findings suggestive of Ectopic PregnancyAbsence of Gestational Sac at bHCG 1800 mIU/ml No mass or free fluid seen (20% likelihood) Free fluid present (71% likelihood of ectopic) Echogenic mass at Adnexa (85% likelihood) Moderate to large free fluid (95% likelihood) Echogenic mass with free fluid (100% likelihood) False positive: corpus luteum (esp. if ruptured) Transvaginal Ultrasound (5 MHz or greater)Test Sensitivity : 90%Test Specificity approaches 100%Gestational Sac of 5 mm (Days 35-37, bHCG 1500-2000)Yolk Sac (Days 37-40, gestation sac>10 mm, confirms intrauterine pregnancy)Fetal Pole (Day 40, Gestational Sac >18 mm, bHCG 5000) Fetal Heart Activity (Day 45, crown rump length >5 mm, bHCG 17,000) Transabdominal UltrasoundGestational Sac (Day 42, bHCG 6000-6500)
Management: OptionsSee Approach below Expectant Management indicationsMinimal pain or bleeding in reliable patient bHCG less than 1000 mIU/ml and falling No signs of tubal rupture Adnexal Mass <3 cmNo Embryo nic heart beat Cohen (1999) Clin Obstet Gynecol 42:48-54 Medical Management: Methotrexate See Methotrexate Ectopic Protocol Stable vital signs with normal LFTs, CBC, platelets Unruptured Ectopic Pregnancy without cardiac activity Ectopic mass 3.5 cm or less bHCG <5000 mIU/ml Surgical Management IndicationsFailed or contraindicated non-surgical management Nondiagnostic Transvaginal Ultrasound and bHCG >1500 Hemoperitoneum Diagnosis unclear Advanced Ectopic Pregnancy Non-compliant patient Unstable vital signs
Approach: Ultrasound, bHCG with D&CIndicationsPregnancy with cramping and Vaginal Bleeding Patient stable Step 1: Pelvic UltrasoundIntrauterine Pregnancy: Routine prenatal care Ectopic Pregnancy: Surgical intervention Abnormal Intrauterine Pregnancy: D&C (see Step 3) Non-Diagnostic Ultrasound: Go to Step 2 below Step 2: Quantitative hCG Transvaginal Ultrasound discriminatory HCG: 1500 mIUHCG less than discriminatory levels: Go to Step 4 HCG exceeds discriminatory levels: Go to Step 3 Step 3: Dilatation and Curettage (if HCG > cutoff)D&C shows chorionic villi: Routine care for failed intrauterine pregnancy D&C shows no chorionic villi: Surgery for Ectopic Step 4: Serial Quantitative hCG (if HCG < cutoff)Normal fall: Manage as Miscarriage Abnormal rise or fall in HCG: D&C (see Step 3) Normal HCG riseUltrasound when HCG > cutoff Go to Step 1
Approach: Ultrasound, bHCG with Culdocentesis and D&CPrecaution: Old protocol listed for completenessCuldocentesis rarely performed in United States now Protocol above is more typical Step 1: Culdocentesis indicationsPatient stable Quantitative hCG exceeds discriminatory levelsUltrasound shows no intrauterine Gestational Sac Step 2: Early Surgical Intervention IndicationsCuldocentesis positive (non-clotting blood) Peritoneal signs present Step 3: Indications to follow bHCG and UltrasoundPatient Stable No peritoneal signs Step 4: Indications Dilatation and Curettage (D & C)bHCG rises abnormally Step 5: Indications for Surgical InterventionNo chorionic villi on D & C frozen section Step 6: Methotrexate Ectopic Protocol IndicationsPatient is compliant Early Ectopic Pregnancy Quantitative hCG increases or plateaus Step 7: Expectant Management IndicationsQuantitative bhCG <1000 and falling
Prognosis: Future conceptionConception rate post-ectopic: 77% Recurrent Ectopic Pregnancy riskAfter first Ectopic Pregnancy: 5-20% risk After second Ectopic Pregnancy: 32% risk
ReferencesSimpson in Gabbe (2002) Obstetrics, p. 743 Della-Giustina (2003) Emerg Med Clin North Am, p. 565 Gracia (2001) Obstet Gynecol 97:464-70 Lozeau (2005) Am Fam Physician 72:1707-20 Tay (2000) West J Med 173:131-4