ECTOPIC PREGNANCY

Epid. MC site = fallopian tubes, specifically the ampulla Site w/ greatest risk of rupture = intramural portion of fallopian tubes (Cornual Pregnancy) Ectopic Pregnancy is the MCC of pregnancy-related maternal death in T1. incidence (~1:1000) may be 2 to in assisted fertility, STIs, & PID. More common in women >35YO Previous ectopic pregnancy (#1 MC risk factor) History of tubal surgery (7:1,000 for tubal ligation) PID, endometritis, or current gonorrhea/chlamydia infection Pelvic adhesive disease (infection, prior surgery) Use of an IUD (absolute risk of ectopic preg. overall, but risk of pregnancy being ectopic if pregnancy occurs) Use of assisted reproductive technologies (e.g., IVF, embryo transfer) DES exposure in utero Cigarette smoking Disorders that affect ciliary motility may be at increased risk. VB Tender adnexal mass Pelvic pain, unilateral Sx of Rupture - hypotension - tachycardia - abdominal rebound tenderness (2 to hemoperitoneum) *Always check a pregnancy test on all reproductive age women with abdominal pain and/or VB Threatened Abortion Ovarian Torsion PID Acute appendicitis Ruptured Ovarian Cyst Tubo-ovarian Abscess Degenerating Uterine Leiomyoma URINE PREGNANCY TEST (UPT) will be positive 1wk after conception when -hCG>25 QUANTITATIVE SERUM -hCG - -hCG should by 66% every 48hrs in first 7wks of gestation after day 9. If rise is less, suspect ectopic. - -hCG of 1500-2000: IUP detectable w/ TVUS. If no evidence of IUP, suspect ectopic. - -hCG of 5000: IUP detectable w/ abdominal US; fetal heartbeat seen. - * -hCG levels do not correlate with: size of ectopic, potential for rupture, location of ectopic, GA of ectopic. PROGESTERONE normal IUP if >25; Abnormal (ectopic or nonviable) if <5. U/S - Modality of choice; TVUS more sensitive than transabdominal U/S - Suspect ectopic pregnancy if TVUS does not detect IUP when -hCG=1500 - Absence of intrauterine gestational sac - Ectopic gestational sac or cardiac activity - Complex adnexal mass - Fluid in the cul de sac (may represent blood from ruptured ectopic pregnancy) - Look out for heterotopic pregnancy (multiple gestation w/ at least one IUP and one ectopic). << R U P T U R E D >> STABILIZE: IV fluids, blood products, pressors EXPLORATORY LAPARTOMY (if hemo. unstable) Stop bleeding and remove ectopic by making large incision on abdominal wall. LAPAROSCOPY (if stable) small incision SALPINGECTOMY - Removing the fallopian tube, (complete vs. partial) - *Partial Salpingectomy: risk of future ectopic preg SALPINGOSTOMY - Removal of ectopic preg, but leaves the tubes intact - Incision on the antimesenteric portion of the tube - Follow -hCG down to zero to ensure complete removal of ectopic tissue. << U N R U P T U R E D >> SALPINGOSTOMY METHOTREXATE (MTX) - Indications: (1) Hemodynamically stable, (2) Size < 3.5cm, (3) Px compliant for f/u (4) IUP has been r/o - Relative Contraindications: (1) fetal cardiac activity of ectopic preg., (2) hCG>15,000, (3) Size >3.5cm - Absolute Contraindications: (1) hemo. Unstable, (2) WBC/platelets, (3) Liver/Renal Dz, (4) PUD, (5) concurrent viable IUP, (6) Ruptured ectopic, (7) Breast-feeding - Monitor: (1) baseline transaminases, (2) Creatinine, (3) serial -hCG, (4) S/Sx of rupture - * Do not coadminister NSAID+MTXnephrotoxicity

RF

H&P

DDx

Dx

Tx

Is Pt acutely symptomatic: hypotension, volume depleted, severe abd/pelvic pain or adnexal mass?

YES Consder laparoscopy or laparotomy

NO

Quantitiatve serum hCG

hCG < 1500-2000

hCG>1500-2000

Serial hCG every 48hr U/S

Transvaginal U/S

Normal Rise (>66%)

Abnormal Rise

IUP Seen

No IUP Seen

Viable IUP

Nonviable Pregnancy

Observe

Consider Laparoscopy

Repeat sono when hCG exceeds threshold

Uterine Curettage

Path: Chorionic Villi

Path: No Villi

Miscarriage (e.g. Threatened Abortion)

Ectopic

Consider MTX