Ectopic pregnancy

Background

  • Must consider in all women of childbearing age who p/w abd/pelvic pain
  • 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)
  • 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

Risk Factors associated with Ectopic Pregnancy[1][2]
Risk Factor 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

Work-Up

  1. Hb (or CBC)[3]
  2. Beta-HCG (quantitative)
  3. Type and Screen with Rh Factor
  4. FAST and Pelvic US

Diagnosis

Clinical Features

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

Diagnostic Algorithm

Estimating the Risk for Ectopic Pregnancy[4]
Clinical Signs and Symptoms Risk Group 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[5]

Step one

  • Assess for Shock
  • 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)[6]
  • If fertility assistance was used then still consider a heterotopic (1% risk)[7]

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.

Repeat B-hCG Levels

Repeat B-hCG Levels

Pregnancy Type B-hCG Change
Normal
  • Minimum expected rise depends on initial hCG value:[8][9]
    • Initial hCG <1,500 mIU/mL: minimum 49% rise in 48hrs
    • Initial hCG 1,500-3,000 mIU/mL: minimum 40% rise in 48hrs
    • Initial hCG >3,000 mIU/mL: minimum 33% rise in 48hrs
  • hCG typically doubles approximately every 48-72 hours in early pregnancy
  • Rate of rise slows after hCG reaches approximately 6,000-10,000 mIU/mL
Ectopic
  • Increases or decreases more slowly than expected ("plateau")
  • Approximately 21% of ectopic pregnancies have a normal hCG rise[10]
Miscarriage
  • Expected to decline >21-35% in 48 hrs[11]
  • A single hCG level cannot reliably distinguish intrauterine from ectopic pregnancy[12]
  • The discriminatory zone (typically 1,500-3,500 mIU/mL depending on institution) is the hCG level above which a gestational sac should be visible on transvaginal ultrasound[13]

Differential Diagnosis

Vaginal Bleeding

Vaginal Bleeding in Pregnancy (<20wks)

Pelvic Pain

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

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
      6. Peptic ulcer disease
      7. Hepatic, renal, or hematologic dysfunction
      8. Alcoholism
      9. Alcoholic or other chronic liver disease
    2. Relative contraindications
      1. Adnexal mass >3.5 cm in largest diameter
      2. Presence of fetal heart rate
      3. Free fluid visualized in Pouch of Douglas
      4. hCG >5000mIU/mL
    3. Note: Need to counsel patient to return after 4 and 7 days to recheck hCG values to check for satisfactory decline
  4. Surgical treatment
    1. Urgent laparotomy if patient is unstable
    2. Otherwise, laparascopic salpingectomy or salpingostomy can be done

External Links

Source

  1. ↑ Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9
  2. ↑ 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.
  3. ↑ Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720
  4. ↑ 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
  5. ↑ 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
  6. ↑ Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419.
  7. ↑ Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a US criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467
  8. ↑ Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004; 104(1):50-55. PMID 15229000.
  9. ↑ Barnhart KT, Guo W, Cary MS, et al. Differences in serum human chorionic gonadotropin rise in early pregnancy by race and value at presentation. Obstet Gynecol. 2016; 128(3):504-511. PMID 27500347.
  10. ↑ Silva C, Sammel MD, Zhou L, et al. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006; 107(3):605-610. PMID 16507930.
  11. ↑ Doubilet PM, Benson CB, Bourne T, Blaivas M. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013; 369(15):1443-1451. PMID 24106937.
  12. ↑ Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005; 173(8):905-912. PMID 16217116.
  13. ↑ Connolly A, Ryan DH, Stuber AR, Postma HJ. Reevaluation of discriminatory and threshold levels for serum beta-hCG in early pregnancy. Obstet Gynecol. 2013; 121(1):65-70. PMID 23262929.
  14. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  • Barnhart KT. Ectopic Pregnancy [clinical practice]. N Engl J Med. 2009;361(4):379-387.
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