Ver el código de «Ectopic pregnancy»

==Background==
*Leading cause of maternal death in first trimester and overall third leading cause of maternal death
*Occur in 2% of all pregnancies<ref>Centers for Disease Control and Prevention. Current trends ectopic pregnancy - United States, 1990-92. MMWR Morb Mortal Wkly Rep. 1995; 44:46-48.</ref> and as high as 6-16% in those presenting to the ED<ref>Houry D and Keadey M. Complications in pregnancy part I: Early pregnancy. EBM. 2007; 9(6):1-28.</ref>
*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<ref>Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9</ref><ref>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.</ref>===
*Risk factors absent in almost half of pts
{|class="wikitable"
| align="center" style="background:*f0f0f0;"|'''Risk Factor'''
| align="center" style="background:*f0f0f0;"|'''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
|}

==Clinical Features==
''Must consider in all women of childbearing age with [[abdominal pain|abdominal]] and/or [[pelvic pain]]''
*Ruptured
**Shock 
**Rebound tenderness
*Non-ruptured (early)
**Abdominal/pelvic pain
**Vaginal bleeding

==Differential Diagnosis==
{{VB DDX less than 20}}

{{Pelvic pain DDX}}

==Diagnosis==
===Work-Up===
*Hb (or CBC)<ref>Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720</ref>
*[[Beta-HCG Levels|Beta-HCG (quantitative)]]
*Type and Screen with Rh Factor
*[[Ultrasound: FAST|FAST]] and [[Ultrasound: Pelvic|Pelvic US]]

===Diagnostic Algorithm===
{| class="wikitable"
|+'''Estimating the Risk for Ectopic Pregnancy<ref>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</ref>'''
| align="center" style="background:*f0f0f0;"|'''Clinical Signs and Symptoms'''
| align="center" style="background:*f0f0f0;"|'''Risk Group'''
| align="center" style="background:*f0f0f0;"|'''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<ref>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</ref>
===Step one===
*Assess for [[Shock]]
**Beware that paradoxical bradycardia can be present with significant hemoperitoneum<ref>Hick JL, et al. Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy. The American Journal of Emergency Medicine. 2001; 19(6)488–491.</ref>
*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)<ref>Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419. </ref>
*If fertility assistance was used then still consider a heterotopic (1% risk)<ref>Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a US criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467</ref>

===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.

===Cervical Ectopic===
*Very rare with delayed diagnoses due to decreased accuracy of US
*As high as 10% with reproductive IVF

===Interstitial Ectopic===
*Typically presents after 8 wks, with rupture possibly occurring as early as 5 wks
*Implantation in myometrium in proximal part of fallopian tube, commonly misdiagnosed on US as intrauterine pregnancy
*65% dx on US and laparascopy is gold standard
*US characteristics:
**Empty uterus
**Gestational sac separate from endometrium
**Gestational sac > 1 cm from lateral aspect of uterine cavity
**< 5 mm mantle surrounding the sac

===Repeat [[B-hCG]] Levels===
{{Repeat B-hCG levels}}

==Treatment==
#[[Rho(D) Immune Globulin (RhoGAM)|RhoGAM]] for all Rh-negative women
#OB/GYN Consult
#Medical management with methotrexate (ACOG)
#*Single dose regimen<ref>Bachman EA and Barnhart K. Medical Management of Ectopic Pregnancy: A Comparison of Regimens. Clin Obstet Gynecol. 2012 Jun; 55(2): 440–447.</ref> 
#**MTX 50 mg IM day 1
#**If hCG decreases by <15% between days 4 and 7, another 50 mg IM MTX on day 7
#*Absolute contraindications
#**Breast-feeding
#**Laboratory evidence of immunodeficiency
#**Preexisting blood dyscrasias (bone marrow hypoplasia, leukopenia, thrombocytopenia, or clinically significant anemia)
#**Known sensitivity to methotrexate
#**Active pulmonary disease
#**Peptic ulcer disease
#**Hepatic, renal, or hematologic dysfunction
#**Alcoholism
#**Alcoholic or other chronic liver disease
#**Coexistant viable IUP
#**Does not have timely access to medical institution, or unwilling/unable to comply with post-MTX monitoring
#*Relative contraindications
#**Adnexal mass >3.5 cm in largest diameter
#**Presence of fetal heart rate
#**Free fluid visualized in Pouch of Douglas
#**[[Beta-HCG]] >5000mIU/mL
#*Note: Need to counsel patient to return after 4 and 7 days to recheck hCG values to check for satisfactory decline
#Surgical treatment
#*Urgent laparotomy if patient is unstable
#*Otherwise, laparascopic salpingectomy or salpingostomy can be done

==See Also==
*[[Pregnancy (main)]]
*[[methotrexate toxicity]]

==External Links==
*[http://www.mdcalc.com/pregnancy-due-dates-calculator/ MDCalc - Pregnancy Due Dates Calculation]

==References==
<references/>

[[Category:OBGYN]]