Ectopic pregnancy: Difference between revisions

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==General==
==Background==
[[File:Figure 28 02 01.png|thumb|Normal female anatomy with uterus highlighted.]]
*Leading cause of maternal death in first trimester and overall third leading cause of maternal death
*Occur in 2% of all pregnancies<ref>Centers for Disease Control and Prevention. Current trends ectopic pregnancy - United States, 1990-92. MMWR Morb Mortal Wkly Rep. 1995; 44:46-48.</ref> and as high as 6-16% in those presenting to the ED<ref>Houry D and Keadey M. Complications in pregnancy part I: Early pregnancy. EBM. 2007; 9(6):1-28.</ref>
*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<ref>Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9</ref><ref>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.</ref>===
''Risk factors absent in almost half of patients''
{|class="wikitable"
| align="center" style="background:*f0f0f0;"|'''Risk Factor'''
| align="center" style="background:*f0f0f0;"|'''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
|}


-EP incidence increasing
===Specific Types by Location===
''Most common location is the ampulla of the fallopian tube''


-Ectopic embryo grows at slower rate since is implanted in tissue not
====Cervical Ectopic====
*Very rare with delayed diagnoses due to decreased accuracy of US
*As high as 10% with reproductive IVF


designed to support its growth.
====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


-HCG levels rise slower or not at all.
==Clinical Features==
''Must consider in all women of childbearing age with [[abdominal pain|abdominal]] and/or [[pelvic pain]]''
*Ruptured
**[[hemorrhagic shock|Shock]]
**Rebound tenderness
*Non-ruptured (early)
**[[abdominal pain|Abdominal]]/[[pelvic pain]]
**[[Vaginal bleeding]]


-Embryo can implant ectopically at ovary, fimbria, ampulla, tube,
==Differential Diagnosis==
{{VB DDX less than 20}}
{{Pelvic pain DDX}}


isthmus, cornua/ interstitial of uterus, or cervix
==Evaluation==
[[File:Ectopic Pregnancy Rutz.gif|thumbnail|Ultrasound shows ectopic pregnancy<ref>http://www.thepocusatlas.com/obgyn/</ref>]]
[[File:Ectopic Ultrasound.png|thumb|Algorithm for the Evaluation of Suspected Ectopic Pregnancy]]
===Work-Up===
*hemoglobin (or CBC)<ref>Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720</ref>
*[[Beta-HCG Levels|Beta-HCG (quantitative)]]
*Type and Screen with Rh Factor
*[[FAST exam|FAST]] and [[Ultrasound: Pelvic|Pelvic US]]


===Diagnostic Algorithm===
''Using this algorithm should always favor considering ectopic if there is any evolution or change in a patient's clinical exam<ref>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</ref>''
{| class="wikitable"
|+'''Estimating the Risk for Ectopic Pregnancy<ref>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</ref>'''
| align="center" style="background:*f0f0f0;"|'''Clinical Signs and Symptoms'''
| align="center" style="background:*f0f0f0;"|'''Risk Group'''
| align="center" style="background:*f0f0f0;"|'''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
|}


==Risk Factors==
====Step one====
*Assess for [[Shock]]
**Beware that paradoxical bradycardia can be present with significant hemoperitoneum<ref>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.</ref>
*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)<ref>Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419. </ref>
*If fertility assistance was used then still consider a heterotopic (1% risk)<ref>Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a [[ultrasound]] criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467</ref>


Prev pelvic/abd surg, smoking, douching, age of 1st
====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


sex <18, PID, in vitro fertilization, multiple sex partners, prev EP,
====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.


prev tubal surg or sterilization, diethystilbesterol exposure in
{{Repeat B-hCG levels}}


utero, documented tubal pathology, use of IUD
==Management==
===Emergency Treatment===
*OB/GYN Consult
*[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] for all Rh-negative women
*If unstable:
**Urgent surgical laparotomy
**Consider T&S and/or [[blood transfusion]] (e.g., [[MTP]]) as temporizing measure


===Definitive Treatment===
*Medical management with [[methotrexate]] (ACOG)
**Single dose regimen<ref>Bachman EA and Barnhart K. Medical Management of Ectopic Pregnancy: A Comparison of Regimens. Clin Obstet Gynecol. 2012 Jun; 55(2): 440–447.</ref>
***[[Methotrexate]] 50mg/m2 IM day 1
***If hCG decreases by <15% between days 4 and 7, another 50mg/m2 IM [[methotrexate]] 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
**Also note that 30-60% of women experience "separation pain" ~1 week after starting methotrexate<ref>Lipscomb GH et al. Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy. Obstet Gynecol. 1999 Apr;93(4):590-3.</ref>
***Thought to be due to tubal distention from tubal abortion or hematoma formation
***Nevertheless, presentation of abdominal pain at this time still warrants an US to look for tubal rupture, which may be indicated by increase in pelvic free fluid, decrease in Hb
***Size of ectopic mass may actually increase before involution, and this is not associated with treatment failure
*Surgical treatment
**Laparascopic salpingectomy or salpingostomy


==Diagnosis==
==Disposition==
*Most are admitted and/or go to the OR
*Smaller, minimally symptomatic ectopic pregnancies being treated with methotrexate may be discharged in consultation with OB/GYN


==See Also==
*[[Pregnancy (main)]]
*[[methotrexate toxicity]]


HCG Levels
==External Links==
*[http://www.mdcalc.com/pregnancy-due-dates-calculator/ MDCalc - Pregnancy Due Dates Calculation]


-Should double q2days until 10000 mIU/ml
==References==
<references/>


-If EP, hcg levels fall, plateau or fail to reach predicted slope before 9- 10 wks gestation.
[[Category:OBGYN]]
 
-1500 mIU/ml should see IUP by transvag utz
 
-6500 = transabd utz
 
 
UTZ
 
-By 2- 3 wks see gest sac followed by yolk sac, then fetal pole and
 
finally cardiac motion (5-6wks)
 
-Consider EP if complex adnexal mass,  or gest sac in fallopian tube
 
-If HCG > 1500 and no IUP - assume EP
 
 
==W/U==
 
 
CBC or Hemaccu
 
T&S
 
B-HCG
 
UA, UCx
 
Pelvic UTZ
 
== ==
 
 
==Treatment==
 
 
-Surgery
 
-Medical management: Methotrexate
 
    -Pt must be hemodynamicallys stable, be reliable, and be  amenable to the treatment regimen
 
    -Methotrexate 50 mg/m2 IM  on day 1 and on day 7 if the beta decreases by less than 15% between  days 4 and 7
 
    Contraindications:
 
          -Adnexal mass >3- 4cm,
 
          -Hcg > 5000
 
          -Cardiac activity
 
          -Suspected twin
 
    -MTX inhibits synthesis of purines and pyrimidines and prevents DNA synthesis and cell division.  Can also cause bone marrow suppression, hepatotoxicity (get LFTs), stomatitis, pulm fibrosis, photosensitivity.  Side effects minimized by leucovorin
 
 
==Persistent EP==
 
 
-Complication of surg.
 
-Trophoblastic tissue retained.
 
-Diagnosed by hcg level not less than 50% of pre op value on 1st post-op day.  Tx with single dose MTX
 
 
==Sources==
 
 
Donaldson, KajiQuestions
 
 
 
 
[[Category:OB/GYN]]

Latest revision as of 20:29, 4 December 2024

Background

Normal female anatomy with uterus highlighted.
  • 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

Specific Types by Location

Most common location is the ampulla of the fallopian tube

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

Clinical Features

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

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

Ultrasound shows ectopic pregnancy[6]
Algorithm for the Evaluation of Suspected Ectopic Pregnancy

Work-Up

Diagnostic Algorithm

Using this algorithm should always favor considering ectopic if there is any evolution or change in a patient's clinical exam[8]

Estimating the Risk for Ectopic Pregnancy[9]
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

Step one

  • Assess for Shock
    • Beware that paradoxical bradycardia can be present with significant hemoperitoneum[10]
  • 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)[11]
  • If fertility assistance was used then still consider a heterotopic (1% risk)[12]

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.

Repeat B-hCG Levels

Pregnancy Type B-hCG Change
Normal
  • Increase >53% in 48hrs (until 10,000 mIU/ml)
  • Depends on the initial value:
    • <1500 --> 50% increase
    • 1500-3000 --> 40% increase
    • > 3000 --> 30% increase
Ectopic
  • Increases or decreases slowly ("plateau")^
Miscarriage
  • Decreases >20% in 48 hrs

^Initial level CANNOT be used to rule-out ectopic

Management

Emergency Treatment

  • OB/GYN Consult
  • RhoGAM for all Rh-negative women
  • If unstable:

Definitive Treatment

  • Medical management with methotrexate (ACOG)
    • Single dose regimen[13]
    • 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
    • Also note that 30-60% of women experience "separation pain" ~1 week after starting methotrexate[14]
      • Thought to be due to tubal distention from tubal abortion or hematoma formation
      • Nevertheless, presentation of abdominal pain at this time still warrants an US to look for tubal rupture, which may be indicated by increase in pelvic free fluid, decrease in Hb
      • Size of ectopic mass may actually increase before involution, and this is not associated with treatment failure
  • Surgical treatment
    • Laparascopic salpingectomy or salpingostomy

Disposition

  • Most are admitted and/or go to the OR
  • Smaller, minimally symptomatic ectopic pregnancies being treated with methotrexate may be discharged in consultation with OB/GYN

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. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  6. ↑ http://www.thepocusatlas.com/obgyn/
  7. ↑ Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720
  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. ↑ 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
  10. ↑ 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.
  11. ↑ Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419.
  12. ↑ Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a ultrasound criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467
  13. ↑ Bachman EA and Barnhart K. Medical Management of Ectopic Pregnancy: A Comparison of Regimens. Clin Obstet Gynecol. 2012 Jun; 55(2): 440–447.
  14. ↑ Lipscomb GH et al. Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy. Obstet Gynecol. 1999 Apr;93(4):590-3.
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