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Ectopic PregnancyAka: Tubal Pregnancy
- See Also
- First Trimester Bleeding
- Methotrexate Ectopic Protocol
- Epidemiology
- Incidence: 2% of all pregnancies
- Second most common cause of maternal mortality
- Accounts for 10-15% of maternal deaths
- Case fatality rate: 3.8 deaths per 10,000 ectopics
- Risk Factors
- Highest risk factors
- Pelvic 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 factors
- Pelvic Inflammatory Disease or other tubal infection
- Infertility (15% of cases)
- Multiple sexual partners
- Other risk factors
- Endometriosis
- Mini Pill use (Progestin only pill)
- Tobacco abuse
- Vaginal Douching
- Early age at first intercourse (age <18 years)
- Symptoms
- Onset occurs ~7 weeks after last menstrual period
- Abdominal Pain
- Vaginal Bleeding
- Signs
- Precaution: Exam can not exclude ectopic pregnancy
- No Vaginal Bleeding in 30% of ectopic pregnancies
- Negative pelvic exam in 10% of ectopic pregnancies
- Buckley (1999) Ann Emerg Med 34:589
- Ectopic chance if Abdominal Pain and Vaginal Bleeding
- No risk factors: 39%
- Risk factors: 54%
- Mol (1999) Hum Reprod 14:2855
- 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 findings
- Adnexal tenderness (54%)
- Amenorrhea
- Shoulder Pain
- BR sign
- Patient 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 Signs
- Orthostasis
- 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
- Decidual cast (Passage of Decidua in one piece)
- Signs suggestive of ruptured ectopic pregnancy
- Severe abdominal tenderness with rebound, gaurding
- Orthostatic Hypotension
- Differential Diagnosis
- Most common alternative diagnoses
- Appendicitis
- Threatened Abortion
- Ruptured Ovarian Cyst (corpus luteum)
- Pelvic Inflammatory Disease
- Salpingitis
- Endometritis
- Nephrolithiasis
- Ovarian torsion
- Intrauterine Pregnancy
- Other alternative diagnoses
- Heterotropic pregnancy
- Dysmenorrhea
- Dysfunctional Uterine Bleeding
- Urinary Tract Infection
- Diverticulitis
- Mesenteric lymphadenitis
- Labs
- See Radiology below
- Quantitative hCG
- Normally will increase by at least 53% every 2 days
- Usually will double in 48 hours
- bHCG with inadequately increase may suggest ectopic
- Test Sensitivity: 36%
- Test Specificity: 65%
- bHCG level does not predict ruptured ectopic
- Ruptured ectopic may occur at any bHCG level
- Blood Type and Rh, hold units
- Complete Blood Count
- Leukocytosis
- Urinalysis with microscopic exam
- Culdocentesis
- Rarely 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 diagnosis
- Serum Progesterone (Test Sensitivity: 15%)
- Radiology
- General
- Findings suggestive of intrauterine pregnancy
- Intrauterine Gestational Sac rules out ectopic
- Exceptions
- Pseudogestational sac (no true Gestational Sac)
- No Echogenic ring
- No Yolk Sac or fetal pole seen
- Heterotopic pregnancy (rare: 0.003% risk)
- Findings suggestive of ectopic pregnancy
- Absence 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
- Test Sensitivity: 90%
- Test Specificity approaches 100%
- Gestational Sac (Days 35-37, bHCG 1500-2000)
- Fetal Pole (Day 40, bHCG 5000)
- Fetal Heart Movement (Day 45, bHCG 17,000)
- Transabdominal Ultrasound
- Gestational Sac (Day 42, bHCG 6000-6500)
- Management: Options
- See Approach below
- Expectant Management indications
- Minimal pain or bleeding in reliable patient
- bHCG less than 1000 mIU/ml and falling
- No signs of tubal rupture
- Adnexal Mass <3 cm
- No Embryonic heart beat
- Cohen (1999) Clin Obstet Gynecol 42:48
- Medical Management: Methotrexate
- See Methotrexate Ectopic Protocol
- Stable vital signs with normal LFTs, CBC, platelets
- Unruptured ectopic pregnancy without cardiac activity
- Ectopic mass <4 cm
- bHCG <5000 mIU/ml
- Surgical Management Indications
- Failed 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&C
- Indications
- Pregnancy with cramping and Vaginal Bleeding
- Patient stable
- Step 1: Pelvic Ultrasound
- Intrauterine 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 mIU
- HCG 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
- 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 rise
- Ultrasound when HCG > cutoff
- Go to Step 1
- Approach: Ultrasound, bHCG with Culdocentesis and D&C
- Step 1: Culdocentesis indications
- Patient stable
- Quantitative hCG exceeds discriminatory levels
- Ultrasound shows no intrauterine Gestational Sac
- Step 2: Early Surgical Intervention Indications
- Culdocentesis positive (non-clotting blood)
- Peritoneal signs present
- Step 3: Indications to follow bHCG and Ultrasound
- Patient Stable
- No peritoneal signs
- Step 4: Indications Dilatation and Curettage (D & C)
- bHCG rises abnormally
- Step 5: Indications for Surgical Intervention
- No chorionic villi on D & C frozen section
- Step 6: Methotrexate Ectopic Protocol Indications
- Patient is compliant
- Early ectopic pregnancy
- Quantitative hCG increases or plateaus
- Step 7: Expectant Management Indications
- Quantitative bhCG <1000 and falling
- Prognosis for future conception
- Conception rate post-ectopic: 77%
- Recurrent ectopic pregnancy risk
- After first ectopic pregnancy: 5-20% risk
- After second ectopic pregnancy: 32% risk
- References
- Simpson in Gabbe (2002) Obstetrics, p. 743
- Della-Giustina (2003) Emerg Med Clin North Am :
- Gracia (2001) Obstet Gynecol 97:464
- Lozeau (2005) Am Fam Physician 72:1707
- Tay (2000) West J Med 173:131
Pregnancy, Ectopic (C0032987)
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| Definition (MSH) | A potentially life-threatening condition in which the EMBRYO, MAMMALIAN implants outside the cavity of the UTERUS. Most ectopic pregnancies (>96%) occur in the FALLOPIAN TUBES, known as TUBAL PREGNANCY. They can be in other locations, such as UTERINE CERVIX; OVARY; and abdominal cavity (PREGNANCY, ABDOMINAL). |
| Definition (CSP) | development of a fertilized ovum outside of the uterine cavity. |
| Concepts | Disease or Syndrome (T047)
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| ICD9 | 633, 633.9 |
| Basque | UMORITZITIK KANPOKO HAURDUNALDIA |
| Danish | Ektopisk svangerskab |
| Dutch | Ectopische zwangerschap |
| English | ECTOPIC PREGN, Ectopic Pregnancies, ECTOPIC PREGNANCY, extrauterine pregnancy, PREGN ECTOPIC, PREGNANCY ECTOPIC, Unspecified ectopic pregnancy |
| Finnish | KOHDUNULKOINEN RASKAUS |
| German | Extrauteringraviditaet |
| Hebrew | herayon mixutz larexem |
| Hungarian | mehen kivuli terhesseg |
| Italian | Gravidanza ectopica |
| Norwegian | EKSTRAUTERINT SVANGERSKAP |
| Portuguese | Gravidez ectopica |
| Spanish | embarazo ectópico, Embarazo ectopico |
| Swedish | EXTRAUTERIN GRAVIDITET |
| Credits | Derived from the NIH UMLS (Unified Medical Language System)
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