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[1] and as high as 6-16% in those presenting to the ED[2]
  • 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[3][4]

Risk factors absent in almost half of patients

Risk Factor Odds Ratio
Previous tubal surgery21
Previous ectopic pregnancy8.3
Diethylstilbestrol exposure5.6
Previous PID2.4 to 3.7
Assisted Fertility2 to 2.5
Smoker2.3
Previous intrauterine device use1.6

Specific Types by Location

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 ultrasound as intrauterine pregnancy
  • 65% diagnosis on ultrasound 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

Clinical Features

Must consider in all women of childbearing age with abdominal and/or pelvic pain

Differential Diagnosis

Vaginal Bleeding in Pregnancy (<20wks)
  • Ectopic pregnancy
  • Subchorionic hematoma
  • First Trimester Abortion
    • Complete Abortion
    • Incomplete Abortion
    • Inevitable Abortion
    • Missed Abortion
    • Septic abortion
    • Threatened Abortion
  • Gestational trophoblastic disease
    • Consider when pregnancy-induced hypertension is seen before 24 wks of gestation
  • Heterotopic pregnancy
  • Implantation bleeding
  • Molar pregnancy
  • Non-pregnancy related bleeding

Pelvic Pain

Pelvic origin

Abdominal origin

Evaluation
Ultrasound shows ectopic pregnancy[5]
Algorithm for the Evaluation of Suspected Ectopic Pregnancy

Work-Up
  • hemoglobin (or CBC)[6]
  • Beta-HCG (quantitative)
  • Type and Screen with Rh Factor
  • FAST and Pelvic US

Diagnostic Algorithm

Using this algorithm should always favor considering ectopic if there is any evolution or change in a patient's clinical exam[7]

Estimating the Risk for Ectopic Pregnancy[8]
Clinical Signs and Symptoms Risk Group Percent Risk of Ectopic (%)
Peritoneal irritation or cervical motion tendernessHigh29
No fetal heart tones; no tissue at cervical os; pain presentIntermediate7
Fetal heart tones or tissue at cervical os; no pain<1

Step one
  • Assess for Shock
    • Beware that paradoxical bradycardia can be present with significant hemoperitoneum[9]
  • 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 ultrasound 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)[10]
  • If fertility assistance was used then still consider a heterotopic (1% risk)[11]

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 follow-up 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
Pregnancy Type B-hCG Change
NormalIncrease >53% in 48hrs (until 10,000 mIU/ml)

(This increase depends on the initial value. <1500 --> 50% inc, 1500-3000 --> 40% inc, > 3000 --> 30% inc)

EctopicIncreases or decreases slowly ("plateau")^
MiscarriageDecreases >20% in 48 hrs

^Initial level CANNOT be used to rule-out ectopic

Management
  1. RhoGAM for all Rh-negative women
  2. OB/GYN Consult
  3. Medical management with methotrexate (ACOG)
    • Single dose regimen[12]
    • 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
    • Also note that 30-60% of women experience "separation pain" ~1 week after starting methotrexate[13]
      • Thought to be due to tubal distention from tubal abortion or hematoma formation
      • Nevertheless, presentation of abdominal pain at this time still warrants an US to look for tubal rupture, which may be indicated by increase in pelvic free fluid, decrease in Hb
      • Size of ectopic mass may actually increase before involution, and this is not associated with treatment failure
  4. Surgical treatment
    • Urgent laparotomy if patient is unstable
    • Otherwise, laparascopic salpingectomy or salpingostomy can be done

Disposition
  • Most are admitted and/or go to the OR
  • Smaller, minimally symptomatic ectopic pregnancies being treated with methotrexate may be discharged in consultation with OB/GYN

See Also

References
  1. Centers for Disease Control and Prevention. Current trends ectopic pregnancy - United States, 1990-92. MMWR Morb Mortal Wkly Rep. 1995; 44:46-48.
  2. Houry D and Keadey M. Complications in pregnancy part I: Early pregnancy. EBM. 2007; 9(6):1-28.
  3. Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65:1093–9
  4. 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.
  5. http://www.thepocusatlas.com/obgyn/
  6. Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72;1707-1714, 1719-1720
  7. 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
  8. 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
  9. 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.
  10. Mukul LV, Teal SB. Current management of ectopic pregnancy. Obstet Gynecol Clin N Am. 2007; 34:403-419.
  11. Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a ultrasound criterion of early intrauterine pregnancy. Radiology. 1986;161:463-467
  12. Bachman EA and Barnhart K. Medical Management of Ectopic Pregnancy: A Comparison of Regimens. Clin Obstet Gynecol. 2012 Jun; 55(2): 440–447.
  13. Lipscomb GH et al. Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy. Obstet Gynecol. 1999 Apr;93(4):590-3.
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