Ectopic Pregnancy PDF

Ectopic Pregnancy
Alberta
District VIII
Midnight Teaching Presentation
Case Presentation
27 yo presents with +++RLQ abdominal

pain x 2 days. Progressively worse. 10/10 at
times. No nausea, no vomiting, no appetite.
Diarrhea x 5
Vaginal spotting x days
LMP 3 weeks ago
Morning-after pill taken ~ 3 weeks ago
Afebrile, VSS
+ McBurneys point tenderness
Pelvic exam:
no cervical motion tenderness

Rt adnexal tenderness
Uterus anteverted and small
Labs
Hb 12.4, WBC 13.8 (No 11.2), Plt 349

Na 137, K 3.2
-hCG 12,060 IU/L
+++ free fluid on abdominal U/S in ER
Transvaginal U/S later by gyne staff empty
uterus, +++clots in abdomen
To OR
Rt tubal ectopic
Laparoscopic Rt linear salpingostomy
Evacuation of hemoperitoneum
Normal-looking Lt tube, uterus, ovaries
No immediate complications
F/U HCG declines to zero (follow hcg since
not a salpingectomy)
Approach
Airway, Breathing, Circulation

Hx, Physical Exam
Quantitative Serum -hCG
Blood type and screen, crossmatch
CBC
Transvaginal ultrasound
Ectopic Pregnancy
Classic triad of:

(1)
(2)
(3)
Also:
Abdominal Pain 90-100%

Amenorrhea 75-85%
Vaginal Bleeding 50-85%
Adnexal tenderness 80-90%
Adnexal mass 40%
50% are asymptomatic before rupture
Ectopic Pregnancy
Developing blastocyst becomes implanted

somewhere besides the endometrium
Most common extra-uterine site is the
fallopian tube (98%)
Despite ++ change in detection and
management, remains the leading cause of
maternal death in 1st trimester (10% of all
maternal deaths)
Risk Factors for Ectopic Pregnancy

Degree of Risk
Risk Factors
High
-Previous Ectopic Pregnancy

-Previous Tubal Surgery
-Tubal Pathology
-In utero DES exposure
Moderate
-Previous genital infections

-Infertility
-Multiple sexual Partners
Low
-Previous Pelvic/Abdo Surgery

-Smoking
-Early age of intercourse (<18yrs)
Where do ectopics
occur?
Sites of ectopic
Fallopian Tube (95%)
factors that delay the passage of fertilized oocyte OR inherent embryonic factors that
force premature implantation
Distribution:
Ovarian (3.2%)
Swelling lateral to insertion of round ligament

Uterine rupture common (20% that progress to 12 weeks)
Abdominal (1.3%)
PID, IUDs, infertility DO NOT increase a womans risk (overall rate of pregnancy
lower)
A random event that does not increase risk for future ectopics
Interstitial/Cornual (2.4%)
Ampullary (70%)
Isthmic (12%)
Fimbrial (11%)
Can be primary (blastocyst implants on viscera) or secondary (extrusion of embryo from

tube)
Wide spectrum of symptoms, and rarely end up with a viable infant
Often need laparoscopy to differentiate abdominal from tubal implantation
Cervical Pregnancy
1:9,000 of all pregnancies-more common when using assisted reproduction

0.1% of IVF pregnancies (3.7% of IVF ectopics)
What are some clinical

signs of an ectopic
pregnancy?
Clinical Manifestations
Typically 6-8 weeks after missed period (later

in interstitial)
Classic symptoms
Shoulder pain
Urge to defecate
May display other symptoms of pregnancy
50% are asymptomatic before rupture and have
no risk factors
Physical Exam
Orthostatic changes
Fever
Cervical motion tenderness
Abdo/pelvic pain or adnexal tenderness
Adnexal mass
Uterine enlargement
NOTHING
What is your
differential diagnosis?
Differential Diagnosis
Miscarriage
Ruptured/bleeding corpus luteum
UTI/calculi, diverticulitis, appendicitis,
adnexal torsion, ruptured ovarian cyst,
torsion/degeneration of fibroid, PID,
endometriosis, abnormal uterine bleeding
May display other symptoms of pregnancy
Diagnosis
Clinical Presentation
Transvaginal ultrasound (TVS) and serial
serum -HCGs are hallmark of diagnosis
Possible laparoscopy
Possible culdocentesis
High risk women should be monitored ASAP
after missed period
Diagnosis of intrauterine pregnancy
Best by seeing true gestational sac (double

echogenic rings), or a yolk sac on ultrasound
Fluid in the uterus produces pseudosac
With TVS
Gestational sac visible at 4.5 to 5 weeks

Yolk sac at 5-6 weeks (until 10 weeks)
Fetal pole with cardiac activity at 5.5-6
NB: leiomyomas can make sacs hard to see
Suggestive Transvaginal U/S

findings of Ectopic Pregnancy
(+) uterine size and decidual response

No yolk sac by 5.5 weeks or with bHCG
>1500-2000mIU/ml
No free fluid in cul de sac
Complex adnexal mass
Diagnosis of extrauterine pregnancy
Sac containing yolk sac or embryo only seen in 1632% of cases

Negative pelvic U/S does not exclude dx of ectopic
Complex adnexal mass and empty uterus is 99%
specific and 85% sensitive for ectopic
Can use colour-flow Doppler (20-45% blood flow
in tube with ectopic)
fluid in belly does not confirm (ruptured cyst)
Postive HCG but negative villi on D&C sample
-HCG
Can be detected 8 days post LH surge

In normal intrauterine pregnancy, doubles
q1.4-2.1 days
Plateaus at 100,000 IU/L at 41 days GA
15% of NORMAL pregnancies do not have
normal doubling
15% of ectopics DO have normal doubling
Same lab is important; 10-15% interassay
variability
What are appropriate

levels for B-hCG?
-hCG is 10 at time of missed menses,

100,000 at 10 weeks and 10,000 at term
~1500 at 5 weeks
~6000 at 6 weeks
Gestational sac can sometimes be seen at hCG of 800 IU/L, but usually 1,500-2,000
IU/L
Absence of intrauterine gestational sac with hCG > 2,000 IU/L suggests ectopic
Laparoscopy
Rare for diagnosis
MRI
Not cost-effective
Culdocentesis
Blood can be from hemorrhagic ovarian cyst
or retrograde menstruation
Natural history of ectopic
Tubal Rupture
Tubal Abortion
Profound hemorrhage
Requires quick surgery
Remains major cause of pregnancy-related maternal
mortality in 1st trimester
Expulsion of products through the fimbria
Can be followed by abdominal pregnancy, ovarian
pregnancy after re-implantation of the trophoblasts
May be accompanied by +++ bleeding
Surgery not always necessary
Spontaneous regression
Treatment for Ectopics
Medical
Surgical
Methotrexate
Has replaced surgical treatment in many cases
Success rate 86-94% (in appropriately selected women)
Laparotomoy/Laparoscopy
Salpingectomy/Salpingostomy
Segmental Resection
U/S guided injection of KCL or MTX
Expectent (only in selected patients)
Methotrexate
Folic acid antagonist

Competitively binds to dihydrofolate reductase, thus
preventing formation of active intracellular
metabolite folinic acid
Purine, pyrimidine (amino acid) metabolism is
dependent on folinic acid
Inhibits DNA metabolism in rapidly dividing cells
(malignant, trophoblast, fetal cells)
Patients should stop taking prenatal vitamins while
being treated
What are the criteria

for medical
management of an
ectopic?
Good candidates for medical Rx
ACOG Criteria
Absolute Indications
Hemodynamic stability
Desiring future fertility
Significant risks for General Anesthesia
No MTX contraindications
Highly reliable patient
Relative Indications
Unruptured mass <3.5 cm

No fetal cardiac motion
BhCG not exceeding 6000-15000mIU/ml
Contraindications
Absolute
Known sensitivity to MTX
Breastfeeding
Active pulmonary disease or peptic ulcer
Hepatic, renal or hematologic dysfunction
Pre-existing blood dyscrasias or anemia
Alcoholism
Evidence of immunodeficiency
Noncompliance
Hemodynamic instability
Relative
Fetal cardiac motion
Gestation sac >3.5 cm
What are the side effects

of methotrexate?
Side Effects
Mild and self-limiting

Stomatitis, conjunctivitis
Nausea/vomiting
Abdominal pain
Rarely, liver enzymes, gastritis, enteritis,
dermatitis, pleuritis, alopecia and bone marrow
suppression
Slightly higher in multi-dose therapy
Indications for surgical treatment
Better for women with -hCG (> 5000IU/L),

large ectopic, fetal cardiac activity (probably)
Ruptured ectopic
Non-compliance
Tubal rupture during medical treatment
Medical vs surgical methods
Several studies suggest success rate is about

the same
Complications slightly higher with medical
treatment
-hCG drop faster with surgery (less post
treatment monitoring)
Need RCT/more cohort studies to compare
salpingostomy and salpingectomy
Expectant management
Different trials have shown success rates of

57-70%
Reasonable when ectopic is suspected, but
TVUS is negative and -hCG is equivocal
Women with cardiac instability, bad pain,
hemoperitoneum should be excluded
Must have close monitoring (tubal rupture)
What about fertility after

an ectopic pregnancy?
Fertility after treatment
Incidence of recurrence is ~15% after one

ectopic, and ~30% after two ectopics
History of infertility is the most important
factor for predicting subsequent fertility
Ipsilateral periadenexal adhesions gives poor
prognosis
Maternal age >35 factor for decreased rate of
subsequent intrauterine pregnancy
Most conceive by 18 months post-ectopic
References
UpToDate
Farquhar and Sowter. Ectopic Pregnancy: an update.
Curr Opin Obstet Gynecol 16 (2004), pp. 289-93.
Stovall et al. Methotrexate treatment of unruptured
ectopic pregnancy: a report of 100 cases. Obstet
Gynecol 77 (1991), pp. 741-53.
Tulandi and Ahmed. Surgical Management of
Ectopic Pregnancy. Clin Obstet Gynecol 42 (1999),
pp. 31-8.
Tulandi and Yoa. Current status of surgical and
nonsurgical management of ectopic pregnancy. Fertil
Steril 67 (1997), pp.421-33.

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Ectopic Pregnancy

27 yo presents with +++RLQ abdominal

no cervical motion tenderness

Hb 12.4, WBC 13.8 (No 11.2), Plt 349

Airway, Breathing, Circulation

Classic triad of:

Abdominal Pain 90-100%

50% are asymptomatic before rupture

Developing blastocyst becomes implanted

Risk Factors for Ectopic Pregnancy

-Previous Ectopic Pregnancy

-Previous genital infections

-Previous Pelvic/Abdo Surgery

Fallopian Tube (95%)

Swelling lateral to insertion of round ligament

Can be primary (blastocyst implants on viscera) or secondary (extrusion of embryo from

1:9,000 of all pregnancies-more common when using assisted reproduction

What are some clinical

Typically 6-8 weeks after missed period (later

Diagnosis of intrauterine pregnancy

Best by seeing true gestational sac (double

Gestational sac visible at 4.5 to 5 weeks

Suggestive Transvaginal U/S

(+) uterine size and decidual response

Diagnosis of extrauterine pregnancy

Sac containing yolk sac or embryo only seen in 1632% of cases

Can be detected 8 days post LH surge

What are appropriate

-hCG is 10 at time of missed menses,

Natural history of ectopic

Treatment for Ectopics

Expectent (only in selected patients)

Folic acid antagonist

What are the criteria

Good candidates for medical Rx

Unruptured mass <3.5 cm

Known sensitivity to MTX

Active pulmonary disease or peptic ulcer

Hepatic, renal or hematologic dysfunction

Pre-existing blood dyscrasias or anemia

Fetal cardiac motion

Gestation sac >3.5 cm

What are the side effects

Mild and self-limiting

Indications for surgical treatment

Better for women with -hCG (> 5000IU/L),

Medical vs surgical methods

Several studies suggest success rate is about

Different trials have shown success rates of

What about fertility after

Fertility after treatment

Incidence of recurrence is ~15% after one

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