Antepartum

Ectopic Pregnancy

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Ectopic Pregnancy, Tubal Pregnancy

  • Definition
  1. Implantation of fertilized ovum outside of the Uterus
  • Epidemiology
  1. Incidence: 2% of all pregnancies
  2. Second most common cause of maternal mortality
    1. Accounts for 6% of maternal deaths (as high as 10-15% of maternal deaths in past)
    2. Case fatality rate: 3.8 deaths per 10,000 ectopics
  • Risk Factors
  1. Highest risk factors
    1. Prior tubal surgery (Odds Ratio 21.0)
    2. Sterilization such as Tubal Ligation (Odds Ratio 9.3)
    3. Prior Ectopic Pregnancy (Odds Ratio 8.3, represents 11% of cases)
    4. Intrauterine Device (IUD) (Odds Ratio 5.0, represents 14% of cases)
    5. In-vitro fertilization
    6. Diethylstilbestrol Exposure (DES Exposure) in utero (Odds Ratio 5.6)
  2. Moderate risk factors
    1. Pelvic Inflammatory Disease or other tubal infection (Odds Ratio 3.4)
    2. Infertility for 2 years or longer (Odds Ratio 2.7, represents 15% of cases)
    3. Multiple sexual partners
    4. Advanced maternal age >40 years old (Odds Ratio 2.9)
    5. Tobacco Abuse (via impaired tubal motility, Odds Ratio 3.9 for 1 ppd, 3.1 for 0.5 ppd)
  3. Other risk factors
    1. Endometriosis
    2. Mini Pill use (Progestin only pill)
    3. Vaginal Douching
    4. Early age at first intercourse (age <18 years)
  • Symptoms
  1. Pregnancy Symptoms (e.g. Amenorrhea, Nausea, Fatigue, Urinary Frequency, Breast engorgement)
  2. Onset of symptoms occurs on average ~7 weeks after Last Menstrual Period
  3. Abdominal Pain (>97% of cases)
    1. May be non-specific, sharp or crampy, diffuse or localized
  4. Vaginal Bleeding (75% of cases)
    1. Varies from spotting to heavy bleeding with clots
  • 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 34:589-94 [PubMed]
  2. Ectopic likelihood if Abdominal Pain and Vaginal Bleeding
    1. No risk factors: 39%
    2. Risk factors: 54%
    3. Mol (1999) Hum Reprod 14:2855-62 [PubMed]
  3. Classic (15-50% 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. Commonly associated findings
    1. Adnexal tenderness (54%)
    2. Amenorrhea
    3. Shoulder Pain
      1. Associated with ruptured Ectopic Pregnancy with Hemorrhage that directly irritates the phrenic nerve
    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. Heterotopic pregnancy
      1. Rare in general population (1 case in 30,000 women)
      2. Common for those undergoing in vitro fertilization (1 case in 100 women)
    2. Dysmenorrhea
    3. Dysfunctional Uterine Bleeding
    4. Urinary Tract Infection
    5. Diverticulitis
    6. Mesenteric Lymphadenitis
  • Labs
  1. See Imaging below
  2. Quantitative hCG
    1. HCG increases by at least 53% (and typically doubles) every 2 days in a normal pregnancy
      1. Levels off after bHCG reaches 100,000 at approximately 8 weeks
    2. bHCG with inadequate increase may suggest ectopic
      1. Test Sensitivity: 36% (some studies report 71%)
      2. Test Specificity: 65%
      3. bHCG also increases inadequately (<50%) in 1% of viable pregancies
      4. bHCG decreases by <35% in up to 7% of 10% of Spontaneous Abortions
    3. bHCG should not be used to defer Ultrasound when Ectopic Pregnancy is considered
      1. Intrauterine pregnancy is first confirmed on Transvaginal Ultrasound at bHCG 1500-2000
      2. However, 40% of ectopic pregnancies are identified at bHCG less than 1000 mIU/ml
      3. Ectopic pregnancies have occurred with bHCG as low as 10 mIU/ml
    4. bHCG level does not predict ruptured ectopic
      1. Ruptured ectopic may occur at any bHCG level
    5. bHCG must be followed serially with all management protocols
      1. Follow bHCG to non-detectable levels (may need as long as 6 weeks)
      2. If bHCG start to rise again after falling, repeat Ultrasound is needed
  3. Blood Type and Rh, hold units
    1. Rh Negative women should be administered 300 mcg (or 50 mcg) RhoGAM if bleeding
  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%)
  • Imaging
  1. Precautions
    1. Transvaginal Ultrasound should be performed regardless of bHCG level when Ectopic Pregnancy is considered
    2. In 40% of Ultrasound diagnosed Ectopic Pregnancy cases, bHCG was below 1000 mIU/ml
    3. Counselman (1998) J Emerg Med 16(5): 699-703 [PubMed]
  2. General
    1. Findings suggestive of intrauterine pregnancy
      1. Intrauterine Gestational Sac suggests intrauterine pregnancy
        1. Central blastocyst
        2. Surrounding double ring of echogenic Decidua and chorionic villi (double Decidua sign, 4.5-5 weeks)
        3. Yolk Sac confirms intrauterine pregnancy wiith PPV 100% (5-6 weeks)
      2. Exceptions
        1. Pseudogestational sac (no true Gestational Sac)
          1. No Echogenic ring
          2. No Yolk Sac or fetal pole seen
        2. Heterotopic pregnancy (Simultaneous intrauterine and Ectopic Pregnancy)
          1. Overall Incidence: 1 in 4000 to 30,000 risk (rare)
          2. Fertility patient Incidence: 1 in 300 (may be 1 in 30 for some types of fertility treatment)
          3. Ultrasound misses heterotopic pregnancy in 50% of cases at 5-6 weeks
    2. Findings suggestive of Ectopic Pregnancy
      1. Absence of Gestational Sac at bHCG 1500-1800
      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 in pouch of Douglas (95% likelihood)
      6. Echogenic mass with free fluid (100% likelihood)
      7. False Positive (free fluid in pouch of douglas)
        1. Ruptured corpus luteum cyst
        2. Spontaneous Abortion
        3. Menses
  3. Transvaginal Ultrasound (5 MHz or greater)
    1. Test Sensitivity: 90%
    2. Test Specificity approaches 100%
    3. Gestational Sac of 5 mm (Days 35-37 or 4.5 to 5 weeks, bHCG 1500-2000)
      1. Earliest finding in pregnancy, but does not exclude Ectopic Pregnancy
      2. Double Decidual sac sign (2 bright concentric ring around the Gestational Sac)
      3. Case reports of absent Gestational Sac on Ultrasound in viable pregnancies with bHCG as high as 4300 mIU/ml
    4. Yolk Sac (Days 37-40 or 5-6 weeks, gestation sac>10 mm)
      1. Confirms intrauterine pregnancy (100% Positive Predictive Value)
    5. Fetal Pole (Day 40, Gestational Sac>18 mm, bHCG 5000)
    6. Fetal Heart Activity (Day 45 or 6-7 weeks, crown rump length >5 mm, bHCG 17,000)
  4. Transabdominal Ultrasound
    1. Gestational Sac (Day 42, bHCG 6000-6500)
    2. Evaluate pouch of douglas for free fluid (see above)
  5. FAST Exam
    1. Free fluid in Morrison's pouch or in Pelvis on Abdominal Ultrasound may warrant emergent surgery
  • Evaluation
  1. Indications
    1. Positive Pregnancy Test AND
    2. Pelvic Pain or Vaginal Bleeding
  2. Step 1: History and physical
    1. Unstable
      1. Go to emergent protocol below
    2. Stable
      1. Go to step 2
  3. Step 2: Transvaginal Ultrasound
    1. Intrauterine pregnancy
      1. Expectant management
    2. Ectopic Pregnancy
      1. See protocols below
  4. Step 3a: Initial bHCG above discriminatory level (e.g. >1500 mIU on Transvaginal Ultrasound)
    1. Treat suspicious Adnexal Mass as Ectopic Pregnancy
    2. Repeat bHCG and Transvaginal Ultrasound in 2 days if no Gestational Sac or Adnexal Mass identified
      1. Treat as Ectopic Pregnancy if bHCG fails to rise appropriately
      2. Treat as normal pregnancy if Transvaginal Ultrasound confirms IUP
      3. Follow weekly bHCG until 0 mIU/ml if decreases
      4. Repeat bHCG and Transvaginal Ultrasound in 2 days if bHCG has normal rise (but nondiagnostic Ultrasound)
  5. Step 3b: Initial bHCG below discriminatory level (e.g. <1500 mIU on Transvaginal Ultrasound)
    1. Repeat bHCG every 48 hours
    2. bHCG decreasing (intrauterine or ectopic failed pregnancy)
      1. Obtain weekly bHCG levels until falls to <5 mIU/ml
    3. bHCG rises normally
      1. Repeat Transvaginal Ultrasound when discriminatory level reached (e.g. <1500 mIU)
    4. bHCG plateaus or with inadequate rise
      1. Obtain Transvaginal Ultrasound
      2. Manage medically or surgically as failed pregnancy (ectopic or intrauterine)
        1. If Transvaginal Ultrasound negative or with Adnexal Mass
  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
      1. See Ectopic Pregnancy Management below
      2. See Methotrexate Ectopic Protocol
    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 for failed intrauterine pregnancy
    2. D&C shows no chorionic villi: Surgery for Ectopic Pregnancy
  5. Step 4: Serial Quantitative hCG (if HCG < cutoff)
    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
    4. Precaution
      1. Symptomatic Ectopic Pregnancy can occur prior to HCG of 1500 (before discriminatory values)
  • Approach
  • Emergent
  1. Indications
    1. Suspected ruptured Ectopic Pregnancy
    2. Hemoperitoneum (significant intraperitoneal fluid presumed to be Hemorrhage)
    3. Hemorrhagic Shock
    4. Abdominal Pain with peritoneal signs
    5. Open cervical os
  2. Evaluation protocol
    1. Consult Ob/Gyn early in suspected Ectopic Pregnancy with hemodynamic instability
      1. Surgical exploration and stabilization is indicated
    2. Obtain IV Access with 2 large bore IVs
    3. Obtain labs as above (including bHCG, Blood Type and Cross)
    4. Fluid Resuscitation and Blood Transfusion for Hemorrhagic Shock
    5. Bedside Transvaginal Ultrasound (if available)
  • Management
  • Treatment protocols
  1. See Approach above
  2. Precautions
    1. Follow bHCG to non-detectable levels regardless of management strategy (up to 6 weeks)
    2. If bHCG start to rise again after falling, repeat Ultrasound is needed
  3. All patients
    1. RhoGAM for Rh negative women with Vaginal Bleeding
  4. Expectant Management indications (counsel regarding tube rupture risk; follow bHCG every 48 hours, then weekly)
    1. Minimal pain or bleeding
    2. Reliable patient with no barriers to follow-up and accessing healthcare
    3. bHCG less than 1000 mIU/ml and falling
    4. No signs of tubal rupture
    5. Ectopic or Adnexal Mass <3 cm or not detected
    6. No Embryonic heart beat
    7. Cohen (1999) Clin Obstet Gynecol 42:48-54 [PubMed]
  5. Medical Management: Methotrexate Indications
    1. See Methotrexate Ectopic Protocol
    2. Reliable patient with no barriers to follow-up and accessing healthcare
    3. Stable Vital Signs with normal LFTs, CBC, platelets
    4. Unruptured Ectopic Pregnancy without cardiac activity
    5. Ectopic mass 3.5 cm or less
    6. bHCG <2000 mIU/ml (or <5000 mIU/ml per some guidelines)
    7. No medical contraindications
      1. Liver, Kidney, lung or hematologic condition
      2. Immunodeficiency
      3. Peptic Ulcer Disease
      4. Alcohol Abuse
      5. Breastfeeding
  6. Surgical Management Indications (Salpingectomy or if desired fertility, and possible, Salpingostomy)
    1. Failed or contraindicated non-surgical management
    2. Nondiagnostic Transvaginal Ultrasound and bHCG >1500
    3. Hemoperitoneum
    4. Diagnosis unclear
    5. Advanced Ectopic Pregnancy (high B-HCG, large mass, Embryonic cardiac activity)
    6. Non-compliant patient
    7. Unstable Vital Signs
  • Prognosis
  • 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