Ectopic pregnancy
Background
What is an ectopic pregnancy?
A fertilized egg implants outside the uterine cavity.
ovarian
abdominal
intramural
ampullar
isthmic
interstitial
cervical
intrauterine
fimbrial
Background
What is an ectopic pregnancy?
A fertilized egg implants outside the uterine cavity.
Risk factors:
*50% of patients have no risk factors!*
Background
What is the differential diagnosis?
Pregnancy-related
Gyne-related
Non-gyne-related
…
All females of reproductive age presenting with an acute abdomen are assumed to have an ectopic pregnancy until proven otherwise!!!
Case
Case #1:
A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain. Their vitals are as follows:
HR: 109bpm
BP: 97/61
RR: 20
SpO2: 99%
Temp: 37.6°C
History
What do you want to know on history?
Case
CASE 1: A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain. Their vitals are as follows:
HR: 109bpm, BP: 97/61, RR: 20, SpO2: 99%, Temp: 37.2°C�
On history, she describes a sharp 5/10 pain in the RLQ that started 2 days ago and has been progressively worsening.
You discover she also has a new 5-week history of amenorrhea with irregular episodes of spotting. She has not had a pregnancy in the past. She is currently sexually active and has an IUD in situ for contraception.
She has a history of Crohn’s disease and has had a laparoscopic ileocecal resection 5 years ago. She is currently taking Azathioprine and vitamin D. She does not have any allergies. She doesn't smoke or use recreational substances. She has about 2 drinks of alcohol per week.
There is no pertinent family history. She is a full-time student in Teachers College and is living with her boyfriend of 2 years.
Exam
What should you look for on exam?
Abdominal
Pelvic
General
Case
CASE 1: A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain. Their vitals are as follows:
HR: 109bpm, BP: 97/61, RR: 20, SpO2: 99%, Temp: 37.2°C�
On exam, vitals are stable. There is tenderness in the suprapubic area without guarding or rebound tenderness. There is no distension and the abdomen is soft. Vaginal exam is normal and there is no cervical motion tenderness.
Investigations
What investigations should you order?
Case
CASE 1: A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain. Their vitals are as follows:
HR: 109bpm, BP: 97/61, RR: 20, SpO2: 99%, Temp: 37.2°C�
Her investigations come back:
CBCdiff
WBC 15.4 (H)
Hb 121
MCV 93
RDW 14.1
Plt 225
Chemistry
ALT 40
AST 12
Bilirubin 11
INR 0.9
Cr 119
serum bHCG 2300 (H)
Urine pregnancy positive
Transvaginal US:
Empty uterine cavity. IUD in situ in good position. There is a gestational sac in the right tubule measuring 2.9cm with no fetal heart rate.
Management
How should you manage patients?
Indications:
Medical management:
Management
How should you manage patients?
Salpingectomy
Total removal of fallopian tube
Indications
Surgical management:
Salpingostomy
Removal of pregnancy tissue while preserving the fallopian tube
Indications
Case
CASE 1: A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain.�
History: sharp 5/10 pain, 5-weeks of amenorrhea with irregular episodes of spotting, IUD in situ
Exam: vitals stable, suprapubic tenderness
Ix: leukocytosis, serum bHCG 2300, +urine pregnancy, tubular ectopic pregnancy on transvaginal US (2.9cm, no fetal HR)
How do you manage this patient?
Case
CASE 1: A 25-year old patient presents to the ER with a 2 day history of acute abdominal pain.�
History: sharp 5/10 pain, 5-weeks of amenorrhea with irregular episodes of spotting, IUD in situ
Exam: vitals stable, suprapubic tenderness
Ix: leukocytosis, serum bHCG 2300, +urine pregnancy, tubular ectopic pregnancy on transvaginal US (2.9cm, no fetal HR)
How do you manage this patient?
She is minimally symptomatic with bHCG <5000, gestational sac <3.5cm with no fetal HR. Therefore, medical management with methotrexate 50 mg/m2 IM x1 dose is indicated. You will also provide her with a lab requisition to measure her bHCG on day 4 and 7 and weekly post-treatment.
Practice
CASE 2: A 37-year old patient presents with 1 day history of acute abdominal pain, fever and N/V.�
History: sharp 9/10 pain, G1P1, not using contraception
Exam: 105bpm, BP 101/79, RR 23, SpO2 98%, temp 38.4ºC
Firm abdomen with suprapubic tenderness and rebound tenderness. Adnexal mass palpable in the LLQ. �Cervical motion tenderness with old blood in the posterior vaginal fornix.
Ix: leukocytosis, serum bHCG 9500, +urine pregnancy test, ampullar ectopic pregnancy on transvaginal US (4.3cm, fetal HR 143bpm)
How do you manage this patient?
Practice
CASE 2: A 37-year old patient presents with 1 day history of acute abdominal pain, fever and N/V.�
History: sharp 9/10 pain, G1P1, not using contraception
Exam: 105bpm, BP 101/79, RR 23, SpO2 98%, temp 38.4ºC
Firm abdomen with suprapubic tenderness and rebound tenderness. Adnexal mass palpable in the LLQ. �Cervical motion tenderness with old blood in the posterior vaginal fornix.
Ix: leukocytosis, serum bHCG 9500, +urine pregnancy test, ampullar ectopic pregnancy on transvaginal US (4.3cm, fetal HR 143bpm)
How do you manage this patient?
She is symptomatic with bHCG >3500, gestational sac >3.5cm and fetal HR is present. Therefore, surgical management is indicated. You plan to perform a salpingostomy as there is no evidence of tubule rupture at present, and the patient indicates that they would like to preserve fertility.
Resources
Interested in learning more? Check out these articles!
�Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies. J Obstet Gynaecol Can. 2021 May;43(5):614-630.e1. doi: 10.1016/j.jogc.2021.01.002. PMID: 33453378.
https://bcmj.org/articles/diagnosis-and-treatment-ectopic-pregnancy
Patient resource: https://www.handouts.ca/pdfs/PregnancyED/Ectopic%20Pregnancy.pdf
Authors
Claudia Turco