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. 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 --> Repeat B-HCG in 48hrs
            2. Rebound and/or shock --> OB/GYN consult
         2. B-HCG below Discriminatory Zone (>1,500-3,000 mIU/ml)
   2. Indeterminate (Pregnancy of Unknown Location)
      1. B-HCG below Discriminatory Zone (<1,500-3,000 mIU/ml)
         1. No rebound/shock --> Repeat B-HCG in 48hrs
         2. Rebound and/or shock --> 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 --> See treatment

^Gestational sac alone does NOT equal IUP (must also have yolk sac) ^^Consider Transabd US for IUP: >6000 mIU/ml

HCG Level

• Helpful in characterizing risk of ectopic, but can NOT be used to rule-out ectopic
  • Normal pregnancy: hCG should double every 2d until 10000 mIU/ml
  • Ectopic pregnancy: hCG increases more slowly or decreases (esp w/ spont. abortion)

DDX

1. All Patients
   1. Appendicitis
   2. IBD
   3. Ovarian pathology
      1. Cyst
      2. Torsion
   4. PID
   5. Endometriosis
   6. Sexual assault/trauma
   7. Urinary tract infection
   8. 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. Surgery
3. Medical management (methotrexate)

Source

Tintinalli