1 - Ectopic pregnancy

 Epidemiology

1. Incidence: 2% of all pregnancies
2. Second most common cause of maternal mortality
1. Accounts for 10-15% of maternal deaths
2. Case fatality rate: 3.8 deaths per 10,000 ectopics

 Risk Factors

1. Highest risk factors
1. Pelvic or tubal surgery (e.g. Tubal Ligation)
2. Prior ectopic pregnancy (11% of cases)
3. Intrauterine Device (IUD) (14% of cases)
4. Diethylstilbestrol Exposure in utero (DES Exposure)
2. Moderate risk factors
1. Pelvic Inflammatory Disease or other tubal infection
2. Infertility (15% of cases)
3. Multiple sexual partners
3. Other risk factors
1. Endometriosis
2. Mini Pill use (Progestin only pill)
3. Tobacco abuse
4. Vaginal Douching
5. Early age at first intercourse (age <18>

 Symptoms

1. Onset occurs ~7 weeks after last menstrual period
2. Abdominal Pain
3. Vaginal Bleeding

 Signs

1. Precaution: Exam can not exclude ectopic pregnancy
1. No Vaginal Bleeding in 30% of ectopic pregnancies
2. Negative pelvic exam in 10% of ectopic pregnancies
3. Buckley (1999) Ann Emerg Med 34:589
2. Ectopic chance if Abdominal Pain and Vaginal Bleeding
1. No risk factors: 39%
2. Risk factors: 54%
3. Mol (1999) Hum Reprod 14:2855
3. Classic (15% of patients)
1. Pelvic Pain or Abdominal Pain (97%)
1. Initially localized pain
2. Pain later generalizes
2. Abdominal tenderness (91%)
3. First Trimester Bleeding (79%)
4. Common associated findings
1. Adnexal tenderness (54%)
2. Amenorrhea
3. Shoulder Pain
4. BR sign
1. Patient faints post Bowel Movement
5. Early Pregnancy Symptoms
6. Cullen's Sign (Periumbilical bruising)
7. Nausea or Vomiting
8. Diarrhea
9. Dizziness
10. Ectopic pregnancy ruptures between 6 and 12 weeks
5. Other Signs
1. Orthostasis
2. Tachycardia
3. Low grade fever
4. Chadwick's Sign (cervix and vaginal cyanosis)
5. Hegar's Sign (softened uterine isthmus)
6. Hypoactive bowel sounds
7. Cervical Motion Tenderness
8. Enlarged uterus
9. Tender pelvic or Adnexal Mass
10. Cul-de-sac fullness
11. Decidual cast (Passage of Decidua in one piece)
6. Signs suggestive of ruptured ectopic pregnancy
1. Severe abdominal tenderness with rebound, gaurding
2. Orthostatic Hypotension

 Differential Diagnosis

1. Most common alternative diagnoses
1. Appendicitis
2. Threatened Abortion
3. Ruptured Ovarian Cyst (corpus luteum)
4. Pelvic Inflammatory Disease
1. Salpingitis
2. Endometritis
5. Nephrolithiasis
6. Ovarian torsion
7. Intrauterine Pregnancy
2. Other alternative diagnoses
1. Heterotropic pregnancy
2. Dysmenorrhea
3. Dysfunctional Uterine Bleeding
4. Urinary Tract Infection
5. Diverticulitis
6. Mesenteric lymphadenitis

 Labs

1. See Radiology below
2. Quantitative hCG
1. Normally will increase by at least 53% every 2 days
1. Usually will double in 48 hours
2. bHCG with inadequately increase may suggest ectopic
1. Test Sensitivity: 36%
2. Test Specificity: 65%
3. bHCG level does not predict ruptured ectopic
1. Ruptured ectopic may occur at any bHCG level
3. Blood Type and Rh, hold units
4. Complete Blood Count
1. Leukocytosis
5. Urinalysis with microscopic exam
6. Culdocentesis
1. Rarely performed now due to Transvaginal Ultrasound
2. Differentiates ruptured Ovarian Cyst from ectopic
3. Yield of aspirate with >15% Hematocrit suggests bleed
7. Tests not recommended for ectopic diagnosis
1. Serum Progesterone (Test Sensitivity: 15%)

 Radiology

1. General
1. Findings suggestive of intrauterine pregnancy
1. Intrauterine Gestational Sac rules out ectopic
2. Exceptions
1. Pseudogestational sac (no true Gestational Sac)
1. No Echogenic ring
2. No Yolk Sac or fetal pole seen
2. Heterotopic pregnancy (rare: 0.003% risk)
2. Findings suggestive of ectopic pregnancy
1. Absence of Gestational Sac at bHCG 1800 mIU/ml
2. No mass or free fluid seen (20% likelihood)
3. Free fluid present (71% likelihood of ectopic)
4. Echogenic mass at adnexa (85% likelihood)
5. Moderate to large free fluid (95% likelihood)
6. Echogenic mass with free fluid (100% likelihood)
7. False positive: corpus luteum (esp. if ruptured)
2. Transvaginal Ultrasound
1. Test Sensitivity: 90%
2. Test Specificity approaches 100%
3. Gestational Sac (Days 35-37, bHCG 1500-2000)
4. Fetal Pole (Day 40, bHCG 5000)
5. Fetal Heart Movement (Day 45, bHCG 17,000)
3. Transabdominal Ultrasound
1. Gestational Sac (Day 42, bHCG 6000-6500)

 Management: Options

1. See Approach below
2. Expectant Management indications
1. Minimal pain or bleeding in reliable patient
2. bHCG less than 1000 mIU/ml and falling
3. No signs of tubal rupture
4. Adnexal Mass <3>
5. No Embryonic heart beat
6. Cohen (1999) Clin Obstet Gynecol 42:48
3. Medical Management: Methotrexate
1. See Methotrexate Ectopic Protocol
2. Stable vital signs with normal LFTs, CBC, platelets
3. Unruptured ectopic pregnancy without cardiac activity
4. Ectopic mass <4>
5. bHCG <5000>
4. Surgical Management Indications
1. Failed or contraindicated non-surgical management
2. Nondiagnostic Transvaginal Ultrasound and bHCG >1500
3. Hemoperitoneum
4. Diagnosis unclear
5. Advanced ectopic pregnancy
6. Non-compliant patient
7. Unstable vital signs

 Approach: Ultrasound, bHCG with D&C

1. Indications
1. Pregnancy with cramping and Vaginal Bleeding
2. Patient stable
2. Step 1: Pelvic Ultrasound
1. Intrauterine Pregnancy: Routine prenatal care
2. Ectopic Pregnancy: Surgical intervention
3. Abnormal Intrauterine Pregnancy: D&C (see Step 3)
4. Non-Diagnostic Ultrasound: Go to Step 2 below
3. Step 2: Quantitative hCG
1. Transvaginal Ultrasound discriminatory HCG: 1500 mIU
2. HCG less than discriminatory levels: Go to Step 4
3. HCG exceeds discriminatory levels: Go to Step 3
4. Step 3: Dilatation and Curettage (if HCG > cutoff)
1. D&C shows chorionic villi: Routine care
2. D&C shows no chorionic villi: Surgery for Ectopic
5. Step 4: Serial Quantitative hCG (if HCG <>
1. Normal fall: Manage as Miscarriage
2. Abnormal rise or fall in HCG: D&C (see Step 3)
3. Normal HCG rise
1. Ultrasound when HCG > cutoff
2. Go to Step 1

 Approach: Ultrasound, bHCG with Culdocentesis and D&C

1. Step 1: Culdocentesis indications
1. Patient stable
2. Quantitative hCG exceeds discriminatory levels
3. Ultrasound shows no intrauterine Gestational Sac
2. Step 2: Early Surgical Intervention Indications
1. Culdocentesis positive (non-clotting blood)
2. Peritoneal signs present
3. Step 3: Indications to follow bHCG and Ultrasound
1. Patient Stable
2. No peritoneal signs
4. Step 4: Indications Dilatation and Curettage (D & C)
1. bHCG rises abnormally
5. Step 5: Indications for Surgical Intervention
1. No chorionic villi on D & C frozen section
6. Step 6: Methotrexate Ectopic Protocol Indications
1. Patient is compliant
2. Early ectopic pregnancy
3. Quantitative hCG increases or plateaus
7. Step 7: Expectant Management Indications
1. Quantitative bhCG <1000>

 Prognosis for future conception

1. Conception rate post-ectopic: 77%
2. Recurrent ectopic pregnancy risk
1. After first ectopic pregnancy: 5-20% risk
2. After second ectopic pregnancy: 32% risk

 References

1. Simpson in Gabbe (2002) Obstetrics, p. 743
2. Della-Giustina (2003) Emerg Med Clin North Am :
3. Gracia (2001) Obstet Gynecol 97:464
4. Lozeau (2005) Am Fam Physician 72:1707
5. Tay (2000) West J Med 173:131