Ectopic pregnancy: Difference between revisions
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==Background==
==Background==
*Must consider in all women of childbearing age who p/w abd/pelvic pain + hypovolemia
*Must consider in all women of childbearing age who p/w abd/pelvic pain
*Leading cause of maternal death in first trimester
*Leading cause of maternal death in first trimester
*Pregnancy in patient with prior tubal ligation or IUD in place is ectopic until proven otherwise (25-50% are ectopic)
*Pregnancy in patient with prior tubal ligation or IUD in place is ectopic until proven otherwise (25-50% are ectopic)
*Heterotopic risk
*Even if an IUP is visualized, there is a small risk of heterotopic ectopic pregnancy
**General Population = 1 per 4000
**General Population = 1 per 4000
**IVF Population = 1 per 100
**IVF Population = 1 per 100

Revision as of 11:24, 4 February 2015

Background

  • Must consider in all women of childbearing age who p/w abd/pelvic pain
  • Leading cause of maternal death in first trimester
  • 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

Risk Factors associated with Ectopic Pregnancy[1][2]
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

Work-Up

  1. Hb (or CBC)[3]
  2. Beta-HCG (quantitative)
  3. Type and Screen with Rh Factor
  4. FAST and Pelvic US

Diagnosis

Clinical Features

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

Diagnostic Algorithm

Estimating the Risk for Ectopic Pregnancy[4]
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[5]

Step one

  • Assess for Shock
  • 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 US 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)[6]
  • If fertility assistance was used then still consider a heterotopic (1% risk)[7]

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 followup 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

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

Differential Diagnosis

Vaginal Bleeding

Vaginal Bleeding in Pregnancy (<20wks)

Pelvic Pain

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Treatment

  1. RhoGAM for all Rh- pts
  2. OB/GYN Consult
  3. Medical management with methotrexate (ACOG)
    1. Absolute contraindications
      1. Breast-feeding
      2. laboratory evidence of immunodeficiency
      3. preexisting blood dyscrasias (bone marrow hypoplasia, leukopenia, thrombocytopenia, or clinically significant anemia)
      4. known sensitivity to methotrexate
      5. active pulmonary disease; peptic ulcer disease
      6. hepatic, renal, or hematologic dysfunction
      7. alcoholism
      8. alcoholic or other chronic liver disease
    2. Relative contraindications
      1. Ectopic mass >3.5 cm
      2. Embryonic cardiac motion
    3. Regimen choice
      1. hCG value <5000 mIU/ml --> single dose
      2. hCG value >5000 mIU/ml --> multi dose
  4. OR, Surgery
    1. Salpingectomy vs. salpingostomy

External Links

Source

  1. ↑ Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9
  2. ↑ 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.
  3. ↑ Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720
  4. ↑ 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
  5. ↑ 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
  6. ↑ Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419.
  7. ↑ Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a US criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467
  8. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  • Barnhart KT. Ectopic Pregnancy [clinical practice]. N Engl J Med. 2009;361(4):379-387.
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