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Ferri: Ferri's Clinical Advisor 2014, 1st ed.

Copyright 2013 Mosby, An Imprint of Elsevier

Ectopic Pregnancy

Basic Information
Definition
An ectopic pregnancy (EP) occurs when a fertilized ovum implants outside the endometrial lining of the uterus.

Synonyms
Abdominal pregnancy (0.03% to 1%) Cervical pregnancy (0.5%) Interstitial pregnancy (1% to 2%) Ovarian pregnancy (1%) Tubal pregnancy (97%)

ICD-9CM CODES
633 Ectopic pregnancy

Epidemiology & Demographics

1% to 2% of pregnancies 13% of maternal deaths

Prevalence (In U.S.)

Increasing number of EPs; 17,800 reported cases in 1970 and currently over 100,000 reported cases/year.

Risk Factors
Previous salpingitis, previous EP, previous tubal ligation, previous tuboplasty, intrauterine device use, progestin-only pill, assisted reproductive techniques

Physical Findings & Clinical Presentation

Abdominal tenderness: 95% Adnexal tenderness: 87% to 99% Peritoneal signs: 71% to 76% Adnexal mass: 33% to 53% Enlarged uterus: 6% to 30% Shock: 2% to 17%

Amenorrhea or abnormal vaginal bleeding: 75% Shoulder pain: 10% Tissue passage: 6% to 7% Anatomic obstruction to zygote passage Abnormalities in tubal motility Transperitoneal migration of the zygote

Etiology

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Ferri: Ferri's Clinical Advisor 2014, 1st ed.

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Diagnosis
Differential Diagnosis
Corpus luteum cyst Rupture or torsion of ovarian cyst Threatened or incomplete abortion Pelvic inflammatory disease Appendicitis Gastroenteritis Dysfunctional uterine bleeding Degenerating uterine fibroids Endometriosis

Workup

1.

The classic presentation of EP includes the triad of abnormal vaginal bleeding, pelvic pain, and an adnexal mass. Fig. E1-300 describes a diagnostic approach to suspected EP. Fig. 1-301 (top)describes potential sites of ectopic implantations. Consider in all women with abdominopelvic pain and a positive pregnancy test Transvaginal ultrasound Quantitative serum human chorionic gonadotropin level Laparoscopy in equivocal situations and possibly for treatment

2. 3. 4.

FIGURE E1-300 Ectopic pregnancy. hCG, Human chorionic gonadotropin.

FIGURE 1-301 Top, Schematic drawing depicting implantation sites of ectopic pregnancies. A and B, Heterotopic pregnancy. This pregnant patient presented with vaginal bleeding at 5 to 6 wk of gestational age. A, Transverse transvaginal ultrasound (TVUS) image of the uterus reveals an intrauterine gestational sac containing a yolk sac. Note small subchorionic hemorrhage (arrows), most likely accounting for the vaginal bleeding. B, Sagittal TVUS image of the right adnexa reveals an echogenic tubal ring (arrow) clearly separate from the right ovary (OV), which was surgically confirmed to be an ectopic pregnancy.(From Fielding JR et al:Gynecologic imaging, Philadelphia, 2011, Saunders.)

Laboratory Tests
Quantitative human chorionic gonadotropin (QhCG): if normal intrauterine pregnancy (IUP), 85% have doubling time of 2 days. If abnormal gestation, will show <66% increase of QhCG within 2 days. However, 13% of ectopic pregnancies have a normal doubling time. Progesterone: decreased production in EP; <5 ng/ml strongly predictive of abnormal pregnancy. If >25 ng/ml, strongly predictive of normal IUP. Dropping hematocrit associated with tubal rupture, resolving EP, or abnormal intrauterine pregnancy. Leukocytosis.

Imaging Studies

Ultrasound: presence of an IUP makes EP extremely unlikely. However, if the patient used assisted reproductive technologies, a heterotopic pregnancy (a pregnancy in the uterus as well as in the fallopian tube) is much more likely to occur (Fig. 1-301, A and B). A repeat ultrasonographic examination 2 to 7 days after presentation may identify the location of a pregnancy that was not identified on initial ultrasonographic examination. If QhCG >6000 mIU/ml, should see IUP on abdominal scan; QhCG >1500 mIU/ml for transvaginal scan. Since transvaginal ultrasonography is overwhelmingly the preferred modality for imaging, the latter value is clearly the discriminatory threshold that is used in diagnosis. Findings on ultrasound in EP include: 1. 2. 3. 4. 5. Empty uterus Adnexal mass Cul-de-sac fluid Fetal sac in tube Fetal cardiac activity in adnexa

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Ferri: Ferri's Clinical Advisor 2014, 1st ed.

Copyright 2013 Mosby, An Imprint of Elsevier

Treatment
Nonpharmacologic Therapy
Surgery can be performed by laparoscopy if patient is stable or, rarely, by laparotomy if patient is very unstable. Salpingiosis is the direct injection of chemotherapy into the EP by laparoscopy, transvaginal ultrasound, or hysteroscopy. Conservative surgery, salpingostomy or segmental resection, depends on tubal location and size of EP. Salpingectomy should be considered in the following circumstances: 1. Ruptured tube

2. 3. 4.

Future fertility not desired Recurrent EP in the same tube Uncontrolled hemorrhage

Acute General Rx
If the patient is stable and compliant, consider medical management with methotrexate. Patient should not have contraindications to methotrexate such as hepatic or renal disease, thrombocytopenia, leukopenia, or significant anemia. There should be no evidence of hemoperitoneum on transvaginal ultrasound. EP should be <3.5 cm mass with QhCG <6,000 to 15,000 mIU/ml, but these are relative contraindications. Presence of cardiac activity in the fetus is also a relative contraindication to methotrexate. Most common regimen is methotrexate 50 mg/m2 of body surface area. May require second dose or surgical intervention if QhCG increases or plateaus (>15% drop) when comparing values from the fourth through seventh day after treatment (day 1 is the day that methotrexate is given). Absolute contraindications to methotrexate include breast feeding, preexisting blood dyscrasias, known sensitivity to methotrexate, active pulmonary disease, chronic liver disease, alcoholism, laboratory evidence of immunodeficiency, renal disease, and peptic ulcer disease.

Chronic Rx
Persistent EP results from residual trophoblastic tissue or secondary implantation after conservative surgery. There is a 5% incidence of persistent EP with conservative treatment.

Disposition
If diagnosed and treated early (before rupture), prognosis is excellent for good recovery. Monitor QhCG weekly until negative. Use reliable contraception until hCG is negative. With subsequent pregnancies, follow QhCG and perform early ultrasound to confirm IUP. There is a 12% recurrence rate for EP.

Referral
Should obtain gynecologic consultation if EP is suspected.

SUGGESTED READINGS
available at www.expertconsult.com

Related Content
Spontaneous Miscarriage (Related Key Topic) Vaginal Bleeding during Pregnancy (Related Key Topic) Ectopic Pregnancy (Patient Information) AUTHORS: GEORGE T. DANAKAS, M.D., and RUBEN ALVERO, M.D.
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