Ectopic Pregnancy sunysbob

					                                                                                     6B
                             ECTOPIC PREGNANCY
Introduction
      Ectopic pregnancy often does not present with a standard clinical picture. This
      leads to frequent delays in diagnosis and helps contribute to this being the
      number one cause of maternal death during the 1 st trimester. Therefore, the
      diagnosis should be considered for all reproductive patients presenting with any
      clinical factors discussed below.
Definition
      An ectopic pregnancy is a pregnancy outside of the uterus. 95% of ectopic
      pregnancies are located within the fallopian tube, 2% are interstitial, 2% are
      ovarian and the remainder are cervical or abdominal. Concomitant intrauterine
      plus ectopic pregnancy (heterotopic) can occur, but it is extremely rare.
Incidence
      In 1992 the CDC reported the incidence of ectopic pregnancy to be
      approximately 2%, a 6-fold increase over the previous 25 years. Heterotopic
      implantation is rare in spontaneous pregnancy (1 in 10,000 -50,000) but more
      common in women undergoing assisted reproductive technologies (0.3-1%).
Risks/Associated Factors
      Risk factors for ectopic pregnancy include a history of:
         previous tubal surgery
         previous ectopic pregnancy
         in utero DES exposure
         history of pelvic inflammatory disease
         history of infertility
         history of chlamydia or gonococcal cervicitis
         tubal abnormality
         tubal ligation
         current or past history of use of an intrauterine device
         tobacco smoking either past or current
         previous spontaneous or induced abortion
         age 40 years and older
Clinical Picture
      The diagnosis of ectopic pregnancy should be considered in any fertile woman
      presenting with any of the following and a positive pregnancy test:
         pelvic or lower abdominal pain
         abnormal vaginal bleeding
         pelvic tenderness
         adnexal mass
        evidence of hemodynamic instability
     Patients may have any one or combination of the above. If rupture has occurred,
     the symptoms will probably be more severe.
Diagnosis
     Diagnosis is made by history and physical exam in conjunction with one or serial
     serum beta-HCGs and a pelvic ultrasound. The combined approach of
     measurement of beta-HCG and transvaginal ultrasound detects ectopic
     pregnancy with 97% sensitivity and 95% specificity, avoiding the need for further
     invasive tests, such as a dilatation and curettage. Vaginal sonography is highly
     accurate. If not available, transabdominal ultrasound can be done. In the
     absence of obvious signs of an ectopic pregnancy, an intrauterine gestation is
     usually visible on transvaginal scan at a beta-HCG concentration of 2000 IU/L. If
     only transabdominal ultrasound is available, the discriminatory zone of beta-HCG
     is 6500 IU/LK. In the case of multiple pregnancies, beta-HCG concentrations will
     be greater than 2000 IU/L before the intrauterine gestation sacs are visible on
     ultrasound.
     The diagnosis can be excluded if a pelvic ultrasound confirms the presence of an
     intrauterine pregnancy (except in rare cases of heterotopic pregnancy), or if
     products of conception from a spontaneous abortion or uterine curettage
     examined by a pathologist confirm the presence of placental or fetal tissue.
     When no intrauterine pregnancy (IUP) is visualized on ultrasound, the differential
     diagnosis includes a pregnancy that is too early to be seen, a spontaneous
     abortion, an abnormal intrauterine pregnancy, or an ectopic pregnancy.
     Diagnosis is suggestive when ultrasonic findings include a complex adnexal
     mass, fluid in the cul-de-sac, or fluid in the cul-de-sac with a cystic adnexal mass.
     A small amount of fluid can be seen in both normal and abnormal pregnancies,
     but the presence of a large amount of fluid or complex fluid is more consistent
     with an ectopic pregnancy. Diagnosis of ectopic pregnancy is also suggested
     when histological examination of the tissue from a dilatation and curettage
     reveals no products of conception with a rising beta-HCG.
     Problems that can complicate the diagnosis include recent elective abortion that
     may have missed an ectopic pregnancy, patient report of passage of tissue that
     is not products of conception, and intermittent symptoms.
     As noted above, heterotopic pregnancy is extremely rare, but more common in
     women undergoing assisted reproductive technologies. The following are signs
     of heterotopic pregnancy:
        ultrasound shows uterine and ectopic gestations
        clinically suspicion of ectopic pregnancy without vaginal bleeding
        rising or persistent hCG levels following D&C for abortion (induced or
         spontaneous)
        uterine size is larger than expected for the gestational age
Evaluation
     Patients must undergo a physical examination. Any signs of hemodynamic
     instability or acute abdomen must be treated immediately and will probably
     require surgical intervention.
     A serum beta-HCG is useful to determine the possibility of seeing the pregnancy
     on ultrasound. A normal intrauterine pregnancy should be accompanied by a
     beta-HCG that doubles every 48 hours, through approximately the 5th week of
     pregnancy.
     A low serum progesterone is indicative of an abnormal pregnancy, but cannot
     distinguish between an ectopic or abnormal IUP. A pelvic ultrasound should be
     obtained.
     Type & Rh: If an Rh(-) patient turns out to be pregnant and is bleeding or has an
     ectopic, RhIG should be given (see Section 4B RhAb Screening, page 10.00).
     A complete blood count with platelets should be obtained. If considering
     treatment with methotrexate, baseline LFTs can be obtained.
     Differential
     Other conditions should be considered in patients who are pregnant where an
     accurate ultrasound has ruled out ectopic.
     The patient may have a ruptured corpus luteum with ultrasound possibly showing
     a cyst and intraperitoneal blood along with an intrauterine pregnancy. As many
     as half of these patients may require surgery for bleeding control. (3) Discuss with
     an OB consultant.
     Other conditions include adnexal torsion and appendicitis – see Section 6B
     Appendicitis in Pregnancy, page 56.00.
Management
     Patients with evidence of tubal rupture or hemodynamic instability must be
     treated immediately and often require surgical intervention. The type of surgery
     performed will depend upon the individual situation and the desires of the patient.
     Patients who are hemodynamically stable with an unclear clinical picture may be
     followed closely as an outpatient until a sure diagnosis can be made. They may
     require serial beta-HCGs and follow up ultrasounds.
     Once a diagnosis of ectopic pregnancy is made, treatment can either be surgical
     or medical. This decision should be based on the individual's situation and
     desires. Surgical management consists of laparoscopy or laparotomy depending
     on the clinical situation, future fertility desires of the patient, and availability of
     OR. Surgical decisions include salpingectomy versus salpingostomy. Medical
     management consists of methotrexate use. The administration of methotrexate
     is dependent upon the size of the ectopic mass, desire for future fertility, ability of
     the patient to follow up, and hemodynamic stability.(1) If there is a question about
     the patient's ability to follow up (e.g., poor compliance pattern, geographical
     limitations), the laparoscopic approach may be safer.
      ACOG has outlined absolute and relative indications and contraindications to
      receiving methotrexate in their Practice Bulletin form 1998.
      Absolute Indications Include:
         hemodynamic stability
         non-laparoscopic diagnosis
         patient desires future fertility
         general anesthesia poses a significant risk
         patient is able to return for follow up care
         patient has no contraindications to methotrexate
      Relative Indications Include:
         unruptured mass  to 3.5cm at its greatest dimension
         no fetal cardiac motion seen
         patients whose beta-HCG level does not exceed a predetermined value
          (6,000 to 15,000 mIU/mL)
      Absolute Contraindications Include:
         breast feeding
         overt or laboratory evidence of immunodeficiency
         alcoholism, alcoholic liver disease, or other chronic liver disease
         preexisting blood dyscrasias
         known sensitivity to methotrexate
         active pulmonary disease
         peptic ulcer disease
         hepatic, renal, or hematologic dysfunction
      Relative Contraindications Include:
         gestational sac  to 3.5cm
         embryonic cardiac motion
      Patients receiving methotrexate should receive close follow up and serial beta-
      HCGs. These patients should be counseled to avoid folic acid supplements,
      sexual intercourse, and alcohol while receiving treatment. Some early
      unruptured ectopic pregnancies have been seen to resolve spontaneously
      without treatment. The best candidates for expectant management have beta-
      HCGs less than 2000IU/L upon initial presentation. These patients need close
      follow up with serial beta-HCGs and ultrasounds.
      The chance on having a normal live-born infant with a subsequent pregnancy is
      85%. After 2 ectopic pregnancies, the risk of having a 3rd ectopic pregnancy is
      increased 10-fold.
Patient Education
      Distribute the pink patient education sheet 6B(1) Abdominal Pain in Pregnancy
      and 6B(5) Ectopic Pregnancy to anyone being sent home for outpatient follow up.
Risks to Mother
      The most immediate risk is shock and death. Ectopic pregnancies are the
      leading cause of pregnancy-related death during the 1st trimester. There is
      increased risk for future fertility problems and recurrent ectopics.
Risks to Fetus
      The risks include nonviability.
Risk Factor
      If the diagnosis is made, add to area 31 of the Flow Sheet: tubal ectopic
      pregnancy.
References
      1. The American College of Obstetricians and Gynecologists: Medical management of tubal
                                                                       th
         pregnancy. ACOG Practice Bulletin. Number 3, (ACOG, 409 12 St., SW, PO Box 96920,
         Washington, DC 20090-6920), December 1998.
      2. Seeber BE, Barnhart KT: Suspected ectopic pregnancy. Obstet Gynecol, 107:399-413,
         2006.
      3. Murray H, Baakdah H, Bardell T, Tulandi T: Diagnosis and treatment of ectopic pregnancy.
         CMAJ, 173:905-912, 2005.
      4. Farquhar CM: Ectopic pregnancy. Lancet; 366:583-591, 2005.
Special Instructions
                                                                                      Upd IV,13,07

				
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