ECTOPIC PREGNANCY

Definition gestation that implants outside of the endometrial cavity Incidence 1/100 clinically recognized pregnancies fourth l...

Definition

gestation that implants outside of the endometrial cavity
Incidence

1. 1/100 clinically recognized pregnancies
2. fourth leading cause of maternal mortality
3. increase in incidence over the last 3 decades

Etiology

1. obstruction or dysfunction of tubal transport mechanisms
2. intrinsic abnormality of the fertilized ovum
3. conception late in cycle
4. transmigration of fertilized ovum to contralateral tube 
   

Risk Factors

1. history of PID
2. past or present IUD
3. use previous lower abdominal surgery
4. previous ectopic pregnancy
5. endometriosis
6. uterine or adnexal mass
7. assisted reproductive techniques

Symptoms

1. vaginal bleeding or spotting (most common)


• due to low Beta-HCG production by the ectopic trophoblast
• heavy vaginal bleeding rare


2. amenorrhea, other symptoms of pregnancy
3. lower abdominal pain (usually unilateral)


• abdominal distension


4. adnexal fullness if ectopic pregnancy ruptures


• acute abdomen
• abdominal distension


5. symptoms of shock

Physical Examination

1. firm diagnosis is usually possible in 50% on clinical features alone
2. hypovolemia/shock
3. guarding and rebound tenderness
4. bimanual examination


• cervical motion tenderness
• adnexal tenderness (unilateral vs bilateral in PID)
• palpable adnexal mass (< 30%)
• uterine enlargement


• rarely increases beyond equivalent of 6-8 weeks gestation


5. other signs of pregnancy, i.e. Chadwick sign, Hegar sign

Diagnosis

1. serial Beta-hCG levels


• normal doubling time with intrauterine pregnancy is 1.4-2 days in early pregnancy which increases until 8 weeks, then decreases steadily until 16 weeks
• prolonged doubling time, plateau or decreasing levels before 8 weeks, implies non-viable gestation but does not provide information on the location of pregnancy


2. ultrasound


• intrauterine sac should be visible when serum Beta-hCG is


• > 1500 mIU/mL (transvaginal)
• > 6000 mIU/mL or 6 weeks gestational age (transabdominal)


• when flhCG is greater than the above values and neither a fetal heart beat nor a fetal pole is seen, it is suggestive of ectopic pregnancy


3. culdocentesis (rarely done)
4. laparoscopy (for definitive diagnosis)

Differential Diagnosis

GYNECOLOGIC PROBLEMS

1. Threatened or incomplete abortion
2. Ruptured corpus luteum cyst
3. Acute pelvic inflammatory disease
4. Adnexal torsion
5. Degenerating leiomyoma (especially in pregnancy)

NONGYNECOLOGIC PROBLEMS

1. Acute appendicitis
2. Pyelonephritis
3. Pancreatitis

Treatment

1. goals of treatment


• be conservative
• try to save the tube

Surgical (laparoscopy)

1. linear salpingostomy or salpingectomy
2. blood loss is replaced if life threatening
3. if patient is Rh negative give anti-D gamma globulin (Rhogam)
4. may require laparotomy 

Medical

1. criteria


• < 3 cm unruptured ectopic pregnancies and no fetal heart activity
• patient clinically stable
• compliance and follow-up ensured


2. methotrexate (considered standard care)


• 1/5 to 1/6 chemotherapy dose, therefore minimal side effects


3. follow Beta-hCG levels


• plateau or rising levels are evidence of persisting trophoblastic tissue
• requires further medical or surgical therapy


4. failure rate 5%


• requires longer follow-up than surgical treatment in order to follow Beta-hCG levels

Prognosis

1. 5% of maternal deaths
2. 40-60% of patients will become pregnant again after surgery 
3. 10-20% will have subsequent ectopic gestation 
4. prognosis for future pregnancy improves with more conservative treatment