Ectopic pregnancy

General

1. EP incidence increasing
2. Ectopic embryo grows at slower rate since is implanted in tissue not designed to support its growth.
3. HCG levels rise slower or not at all.
4. Embryo can implant ectopically at ovary, fimbria, ampulla, tube, isthmus, cornua/ interstitial of uterus, or cervix

Risk Factors

1. Prev pelvic/abd surg, smoking, douching, age of 1st
2. sex <18, PID, in vitro fertilization, multiple sex partners, prev EP,
3. prev tubal surg or sterilization, diethystilbesterol exposure in utero, documented tubal pathology, use of IUD

Diagnosis

1. HCG Levels
   1. Should double q2days until 10000 mIU/ml
   2. If EP, hcg levels fall, plateau or fail to reach predicted slope before 9- 10 wks gestation.
   3. 1500 mIU/ml should see IUP by transvag utz
   4. 6500 = transabd utz
2. UTZ
   1. By 2- 3 wks see gest sac followed by yolk sac, then fetal pole and finally cardiac motion (5-6wks)
   2. Consider EP if complex adnexal mass, or gest sac in fallopian tube
   3. If HCG > 1500 and no IUP - assume EP

Workup

1. CBC or Hemaccu
2. T&S
3. B-HCG
4. UA, UCx
5. Pelvic UTZ

Treatment

1. Surgery
2. Medical management: Methotrexate
   1. Pt must be hemodynamicallys stable, be reliable, and be amenable to the treatment regimen
   2. 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
   3. Contraindications:
      1. Adnexal mass >3- 4cm,
      2. Hcg > 5000
      3. Cardiac activity
      4. Suspected twin
   4. 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

1. Complication of surg.
2. Trophoblastic tissue retained.
3. 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