Ectopic pregnancy: Difference between revisions

Revision as of 02:42, 20 August 2011

Background

Must consider in all women of childbearing age who p/w abd/pelvic pain + hypovolemia
Leading cause of maternal death in first trimester
Pregnancy in pt w/ prior tubal sx for sterilization is ectopic until proven otherwise

Risk Factors

PID
History of tubal surgery
IUD
Assisted reproduction techniques
Previous ectopic

Diagnosis

Clinical Features

Abdominal/pelvic pain
Vaginal bleeding
Amenorrhea

HCG Level

Helpful in characterizing risk of ectopic, but can NOT be used to rule-out ectopic
- Normal pregnancy: hCG should double every 2d until 10000 mIU/ml
- Ectopic pregnancy: hCG increases more slowly or decreases (esp w/ spont. abortion)

Ultrasound: Pelvic

Used to identify presence or absence of IUP
- IUP in setting of fertility tx does not necessarily r/o ectopic (heterotopic pregnancy)
Discriminant zone
- There is no discriminant zone for an ectopic pregnancy:
  - Perform US if ectopic is suspected regardless of the hCG level
- Transvag US for IUP: 1500 mIU/ml
  - If hCG > 1500 and no IUP - assume EP
- Transabd US for IUP: 6000 mIU/ml
Findings
- Gestational sac alone does NOT equal IUP (must also have yolk sac)

DDX

All Patients
1. Appendicitis
2. IBD
3. Ovarian pathology
  1. Cyst
  2. Torsion
4. PID
5. Endometriosis
6. Sexual assault/trauma
7. Urinary tract infection
8. Ureteral colic
Pregnant Patients
1. Normal (intrauterine pregnancy)
2. Threatened abortion
3. Inevitable abortion
4. Molar pregnancy
5. Heterotopic pregnancy
6. Implantation bleeding
7. Corpus luteum cyst

Work-Up

Hb
hCG quant
T&S
UA
Pelvic US

Treatment

RhoGAM for all Rh- pts
Surgery
Medical management (methotrexate)

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
-==General==
+==Background==
-#EP incidence increasing
+*Must consider in all women of childbearing age who p/w abd/pelvic pain + hypovolemia
-#Ectopic embryo grows at slower rate since is implanted in tissue not designed to support its growth.
+*Leading cause of maternal death in first trimester
-#HCG levels rise slower or not at all.
+*Pregnancy in pt w/ prior tubal sx for sterilization is ectopic until proven otherwise
-#Embryo can implant ectopically at ovary, fimbria, ampulla, tube, isthmus, cornua/ interstitial of uterus, or cervix
-==Risk Factors==
+===Risk Factors===
-#Prev pelvic/abd surg, smoking, douching, age of 1st
+#PID
-#sex <18, PID, in vitro fertilization, multiple sex partners, prev EP,
+#History of tubal surgery
-#prev tubal surg or sterilization, diethystilbesterol exposure in utero, documented tubal pathology, use of IUD
+#IUD
+#Assisted reproduction techniques
+#Previous ectopic
 ==Diagnosis==
-#HCG Levels
+===Clinical Features===
-##Should double q2days until 10000 mIU/ml
+#Abdominal/pelvic pain
-##If EP, hcg levels fall, plateau or fail to reach predicted slope before 9- 10 wks gestation.
+#Vaginal bleeding
-##1500 mIU/ml should see IUP by transvag utz
+#Amenorrhea
-##6500 = transabd utz
+===HCG Level===
-#[[Ultrasound: Pelvic|Ultrasound]]
+*Helpful in characterizing risk of ectopic, but can NOT be used to rule-out ectopic
-##By 2- 3 wks see gest sac followed by yolk sac, then fetal pole and finally cardiac motion (5-6wks)
+**Normal pregnancy: hCG should double every 2d until 10000 mIU/ml
-##Consider EP if complex adnexal mass,  or gest sac in fallopian tube
+**Ectopic pregnancy: hCG increases more slowly or decreases (esp w/ spont. abortion)
-##If HCG > 1500 and no IUP - assume EP
+===[[Ultrasound: Pelvic]]===
+*Used to identify presence or absence of IUP
+**IUP in setting of fertility tx does not necessarily r/o ectopic (heterotopic pregnancy)
+*Discriminant zone
+**There is no discriminant zone for an ectopic pregnancy:
+***Perform US if ectopic is suspected regardless of the hCG level
+**Transvag US for IUP: 1500 mIU/ml
+***If hCG > 1500 and no IUP - assume EP
+**Transabd US for IUP: 6000 mIU/ml
+*Findings
+**Gestational sac alone does NOT equal IUP (must also have yolk sac)
-==Workup==
+==DDX==
-#CBC or Hemaccu
+#All Patients
+##Appendicitis
+##IBD
+##Ovarian pathology
+###Cyst
+###Torsion
+##PID
+##Endometriosis
+##Sexual assault/trauma
+##Urinary tract infection
+##Ureteral colic
+#Pregnant Patients
+##Normal (intrauterine pregnancy)
+##Threatened abortion
+##Inevitable abortion
+##Molar pregnancy
+##Heterotopic pregnancy
+##Implantation bleeding
+##Corpus luteum cyst
+==Work-Up==
+#Hb
+#hCG quant
 #T&S
-#B-HCG
+#UA
-#UA, UCx
+#Pelvic US
-#Pelvic UTZ
 ==Treatment==
+#RhoGAM for all Rh- pts
 #Surgery
-#Medical management: Methotrexate
+#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==
+==Source==
-Donaldson, KajiQuestions
+Tintinalli
 [[Category:OB/GYN]]