Ectopic Pregnancy

Ectopic Pregnancy

page sections introduction causes and risk factors signs and symptoms investigations differential diagnosis pathophysiology treatments consequences and course resources and references Ectopic Pregnancy

Ectopic pregnancy (Greek ektopos, or out of place) refers to the implantation of a fertilized egg outside of the uterine cavity. Ectopic pregnancies frequently rupture, leading to hemorrhage - the leading cause of first-trimester dealth due to pregnancy. Approximately 2% of all first trimester pregnancies are ectopic (ACOG, 2008).

Most ectopic pregnancies - 95-96% - occur in the fallopian tubes, with the majority of the rest being ovarian or cervical.

The abnormally implanted blastocyst grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for rupture and hemorrhage - one of its most dangerous complications.

Anything that hampers the migration of the embryo to the endometrial cavity can predispose to ectopic pregnancy. pelvic inflammatory disease - commonly Chlamydia trachomatis (10-15% chance with future pregnancy) multiple sexual partners history of prior ectopic pregnancy (15-20% recurrence rate) prior Caesarean section history of tubal surgery and conception after tubal ligation use of infertility drugs or assisted reproductive technology use of intrauterine devices increasing age smoking salpingitis isthmica nodosa (diverticulosis of the fallopian tube) previous DES exposure T-shaped uterus

Heterotopic pregnancy, where one embryo is ectopic and the other intrauterine, is on the rise due to increased rates of assisted reproductive technology.

However, over half of all cases of ectopic pregnancy occur in women with none of these risk factors.

The classic clinical triad of ectopic pregnancy includes: lower abdominal pain amenorrhea vaginal bleeding

Other symptoms include: dizziness, fainting passage of tissue those common to early pregnancy (nausea, breast fullness, fatigue, heavy cramping etc.)

Inquire into: menstrual history (LMP) sexual history constraceptive use gynecologic history (surgery, infections)

Physical exam may reveal: unstable vitals: tachycardia, hypotension cervical motion tenderness (most frequent sign) adnexal tenderness or mass abdominal tenderness, rebounding, or guarding Cullen sign: blue discoloration around umbilicus suggesting retroperitoneal hemorrhage uterine enlargement fever orthostatic hypotension

When considering ectopic pregnancy, the following may be helpful: beta-HCG: quantitative testing can be done at 48h intervals; it normally doubles in this time with intrauterine pregnancy, and will rise more slowly with ectopic pregnancy serum progesterone may distinguish between viable and nonviable pregnancy

In order to assess stability, and prepare for treatment, consider: CBC Rh type crossmatch Diagnostic Imaging

Transvaginal ultrasound (TVUS) is the preferred modality to identify extrauterine pregnancy. A gestational sac is typically visible, regardless of location, if beta-HCG is more than 1500 IU. However, a negative ultrasound does not exclude ectopic pregnancy.

Ectopic findings include: complex adnexal mass fluid-filled adnexal mass free fluid in the peritoneal cavity gestational sac in the cornual area intracervical location

Other possible conditions include: normal pregnancy appendicitis urinary tract infection ovarian torsion ovarian cyst salpingitis ruptured corpus luteum cyst threatened abortion

Damage to the cilia in Fallopian tubes is frequently responsible for ectopic pregnancy, caused by factors such as pelvic inflammatory disease (PID) or surgery.

Initial focus should be on the ABC's to stabilize the patient: oxygen as needed two large bore IVs and fluid resuscitation CBC and cross-match

Methotrexate is the primary nonsurgical treatment. It can be used in situations of: stable patient no signs of active bleeding patient can be trusted to follow-up

Indications include: unruptured mass 3.5 cm no fetal activity desire for future fertility beta HCG 5000 IU

Contraindications include: active intraabdominal hemorrhage breast feeding immunodeficiency alcoholism chronic hepatic, renal, or lung disease blood dyscrasias peptic ulcer disease

If surgery is warranted, laparascopy followed by salpingectomy or salpingostomy is the preferred approach. Open laparotomy is mandated if the patient is unstable..

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