Ectopic pregnancy

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 patient with prior tubal ligation or IUD in place is ectopic until proven otherwise (25-50% are ectopic)
• Heterotopic risk
  • General Population = 1 per 4000
  • IVF Population = 1 per 100

Risk Factors^

1. Major
   1. H/O PID
   2. History of tubal surgery or IUD in place
   3. Previous ectopic
2. Minor
   1. Tobacco
   2. Assisted reproduction techniques
   3. Age >35
   4. Numerous lifetime partners

^Only 50% of ectopics have a risk factor

Work-Up

1. Hb (or CBC)
2. Beta-HCG (quantitative)
3. T&S (or Rh Factor)
4. FAST and Pelvic US
5. UA?

Diagnosis

Clinical Features

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

Algorithm

1. Pelvic US^
   1. IUP^^
      1. No IVF/fertility medications
         1. Ectopic ruled out
      2. IVF/fertility medications
         1. Consider heterotopic
            1. No rebound/shock
               1. Repeat B-HCG in 48hrs (see Repeat B-hCG Levels)
            2. Rebound and/or shock
               1. OB/GYN consult
   2. Indeterminate (Pregnancy of Unknown Location)
      1. B-HCG below Discriminatory Zone (<1,500-3,000 mIU/ml)
         1. No rebound/shock
            1. Repeat B-HCG in 48hrs (see Repeat B-hCG Levels)
         2. Rebound and/or shock
            1. OB/GYN consult
      2. B-HCG above Discriminatory Zone (>1,500-3,000 mIU/ml)
         1. Ectopic pregnancy until proven otherwise
            1. OB/GYN consult
   3. +Ectopic
      1. See treatment

• ^Consider Transabd US for IUP: >6000 mIU/ml (but if negative or indeterminate must do Pelvic US)
• ^^Gestational sac alone does NOT equal IUP (must also have yolk 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

DDX

1. All Patients
   1. Appendicitis
   2. IBD
   3. Ovarian Cyst
   4. Ovarian Torsion
   5. PID
   6. Endometriosis
   7. Sexual assault/trauma
   8. Urinary Tract Infection
   9. Ureteral Colic
2. 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

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

• MDCalc - Pregnancy Due Dates Calculation

Source

• Tintinalli
• Barnhart KT. Ectopic Pregnancy [clinical practice]. N Engl J Med. 2009;361(4):379-387.