Ectopic pregnancy

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Background

  • Leading cause of maternal death in first trimester and overall third leading cause of maternal death
  • Occur in 2% of all pregnancies[1] and as high as 6-16% in those presenting to the ED[2]
  • Pregnancy in patient with prior tubal ligation or IUD in place is ectopic until proven otherwise (25-50% are ectopic)
  • Even if an IUP is visualized, there is a small risk of heterotopic ectopic pregnancy
    • General Population = 1 per 4000
    • IVF Population = 1 per 100

Risk Factors[3][4]

  • Risk factors absent in almost half of patients
Risk Factor Odds Ratio
Previous tubal surgery 21
Previous ectopic pregnancy 8.3
Diethylstilbestrol exposure 5.6
Previous PID 2.4 to 3.7
Assisted Fertility 2 to 2.5
Smoker 2.3
Previous intrauterine device use 1.6

Clinical Features

Must consider in all women of childbearing age with abdominal and/or pelvic pain

  • Ruptured
    • Shock
    • Rebound tenderness
  • Non-ruptured (early)
    • Abdominal/pelvic pain
    • Vaginal bleeding

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)

  • Ectopic Pregnancy
  • First Trimester Abortion
    • Complete Abortion
    • Incomplete Abortion
    • Inevitable Abortion
    • Missed Abortion
    • Septic abortion
    • Threatened Abortion
  • Gestational trophoblastic disease
    • Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
  • Heterotopic pregnancy
  • Implantation bleeding
  • Molar pregnancy
  • Non-pregnancy related bleeding

Pelvic Pain

Pelvic origin

Abdominal origin

Evaluation

Ultrasound shows ectopic pregnancy[5]

Work-Up

Diagnostic Algorithm

Estimating the Risk for Ectopic Pregnancy[7]
Clinical Signs and Symptoms Risk Group Percent Risk of Ectopic (%)
Peritoneal irritation or cervical motion tenderness High 29
No fetal heart tones; no tissue at cervical os; pain present Intermediate 7
Fetal heart tones or tissue at cervical os; no pain <1
  • Using this algorithm should always favor considering ectopic if there is any evolution or change in a patient's clinical exam[8]

Step one

  • Assess for Shock
    • Beware that paradoxical bradycardia can be present with significant hemoperitoneum[9]
  • If patient is a high risk for ectopic based on above estimation then immediately contact OBGYN

Step Two

Perform a Pelvic US

  • Consider Transabdominal Ultrasound for B-HCG: >6000 mIU/ml (but if negative or indeterminate must do Pelvic ultrasound regardless of B-HCG)

Is there an Intrauterine Pregnancy?

  • If there is an IUP and there was no assisted reproductive fertility used then ectopic ruled out and heterotopic unlikely (less than 1:30,000)[10]
  • If fertility assistance was used then still consider a heterotopic (1% risk)[11]

Step Three

  • If HCG above Discriminatory Zone (>1,500-3,000 mIU/ml) and not visualized it should be an ectopic pregnancy until proven otherwise

Step Four

  • Arrange close follow-up for patients with no visualized IUP and B-HCG( (<1,500-3,000 mIU/ml), with minimal to no pain and hemodynamically stable.
  • Patients should have a 48hr repeat B-HCG level checked to determine if appropriate doubling is occurring.

Cervical Ectopic

  • Very rare with delayed diagnoses due to decreased accuracy of US
  • As high as 10% with reproductive IVF

Interstitial Ectopic

  • Typically presents after 8 wks, with rupture possibly occurring as early as 5 wks
  • Implantation in myometrium in proximal part of fallopian tube, commonly misdiagnosed on ultrasound as intrauterine pregnancy
  • 65% diagnosis on ultrasound and laparascopy is gold standard
  • US characteristics:
    • Empty uterus
    • Gestational sac separate from endometrium
    • Gestational sac > 1 cm from lateral aspect of uterine cavity
    • < 5 mm mantle surrounding the sac

Repeat B-hCG Levels

  • Normal pregnancy
    • B-hCG should increase >53% in 48hrs (until 10,000 mIU/ml)
  • Ectopic pregnancy
    • B-hCG increases or decreases slowly ("plateau")^
  • Miscarriage
    • B-hCG decreases >20% in 48 hrs

^Initial level CANNOT be used to rule-out ectopic

Management

  1. RhoGAM for all Rh-negative women
  2. OB/GYN Consult
  3. Medical management with methotrexate (ACOG)
    • Single dose regimen[12]
      • MTX 50mg IM day 1
      • If hCG decreases by <15% between days 4 and 7, another 50mg IM MTX on day 7
    • Absolute contraindications
      • Breast-feeding
      • Laboratory evidence of immunodeficiency
      • Preexisting blood dyscrasias (bone marrow hypoplasia, leukopenia, thrombocytopenia, or clinically significant anemia)
      • Known sensitivity to methotrexate
      • Active pulmonary disease
      • Peptic ulcer disease
      • Hepatic, renal, or hematologic dysfunction
      • Alcoholism
      • Alcoholic or other chronic liver disease
      • Coexistant viable IUP
      • Does not have timely access to medical institution, or unwilling/unable to comply with post-MTX monitoring
    • Relative contraindications
      • Adnexal mass >3.5 cm in largest diameter
      • Presence of fetal heart rate
      • Free fluid visualized in Pouch of Douglas
      • Beta-HCG >5000mIU/mL
    • Note: Need to counsel patient to return after 4 and 7 days to recheck hCG values to check for satisfactory decline
  4. Surgical treatment
    • Urgent laparotomy if patient is unstable
    • Otherwise, laparascopic salpingectomy or salpingostomy can be done

Disposition

See Also

External Links

References

  1. Centers for Disease Control and Prevention. Current trends ectopic pregnancy - United States, 1990-92. MMWR Morb Mortal Wkly Rep. 1995; 44:46-48.
  2. Houry D and Keadey M. Complications in pregnancy part I: Early pregnancy. EBM. 2007; 9(6):1-28.
  3. Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9
  4. Mol BW, Ankum WM, Bossuyt PM, Van der Veen F. Contraception and the risk of ectopic pregnancy: a meta-analysis. Contraception. 1995;52:337–41.
  5. http://www.thepocusatlas.com/obgyn/
  6. Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720
  7. Buckley RG, King K et. al. History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model. Ann Emerg Med. 1999;34:589–94
  8. American College of Obstetricians and Gynecologists. Medical management of tubal pregnancy. Number 3, December 1998. Clinical management guidelines for obstetricians-gynecologists. Int J Gynaecol Obstet. 1999;65:97–103
  9. Hick JL, et al. Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy. The American Journal of Emergency Medicine. 2001; 19(6)488–491.
  10. Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419.
  11. Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a ultrasound criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467
  12. Bachman EA and Barnhart K. Medical Management of Ectopic Pregnancy: A Comparison of Regimens. Clin Obstet Gynecol. 2012 Jun; 55(2): 440–447.