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Ectopic Pregnancy

Basics

Description

  • Pregnancy implanted outside the uterine cavity.
  • Subtypes:
  • Tubal (95-97%; ampulla 55-80%, isthmus 12-25%, fimbria 5-17%)
  • Abdominal
  • Heterotopic (simultaneous intrauterine and ectopic)
  • Ovarian
  • Cervical
  • Intraligamentary

Epidemiology

  • Incidence: ~2 per 100 pregnancies in the US.
  • 10% of first-trimester pain/bleeding presentations due to ectopic.
  • Leading cause of first-trimester maternal deaths.
  • Recurrence risk ~33% if prior ectopic.
  • Increased incidence of nontubal ectopics due to IVF and cesarean scar pregnancies.

Etiology and Pathophysiology

  • Impaired ovum transport due to ciliary dysfunction, scarring, or tubal lumen narrowing.
  • Risk factors include PID, tubal surgery, IUD, assisted reproduction, tobacco, ciliary motility disorders.

Risk Factors

  • History of PID or sexually transmitted infections.
  • Prior ectopic pregnancy or tubal surgery.
  • IUD use (if pregnancy occurs).
  • Assisted reproductive technologies (IVF).
  • Tobacco use.
  • Endometriosis, Kartagener syndrome.

Prevention

  • Reliable contraception, especially long-acting reversible contraception (LARC).

Diagnosis

History

  • Classic triad: sudden-onset abdominal pain, missed or irregular menses, acute vaginal bleeding (present in >50%).
  • Nausea, vomiting, shoulder pain (hemoperitoneum).

Physical Exam

  • Abdominal tenderness ± rebound.
  • Adnexal or cul-de-sac fullness.
  • Cervical motion tenderness.
  • Signs of shock if ruptured: pallor, tachycardia, hypotension.

Differential Diagnosis

  • Miscarriage variants (threatened, inevitable, incomplete).
  • Gestational trophoblastic disease.
  • Appendicitis, PID, ovarian torsion, hemorrhagic cyst.
  • Cervical pathology, trauma, infection.

Diagnostic Tests

Laboratory

  • CBC, blood type and antibody screen.
  • Serial quantitative serum beta-hCG.

Imaging

  • Transvaginal ultrasound (TVUS) is gold standard.
  • Failure to see intrauterine gestational sac when hCG >1,500-2,000 IU/L suggests ectopic or pregnancy of unknown location (PUL).
  • MRI rarely used; helpful for abdominal or cesarean scar pregnancies.

Other Tests

  • Serum progesterone (>20 ng/mL less likely ectopic but limited utility).
  • Uterine aspiration/D&C for intrauterine chorionic villi.
  • TVUS assessment of pelvic free fluid for hemoperitoneum.

Treatment

Medical Management

  • Methotrexate (MTX) inhibits DNA synthesis by folate antagonism.
  • Candidates: hemodynamically stable, unruptured, <3-4 cm sac, hCG <5,000 mIU/mL, no fetal heart activity.
  • Single-dose protocol preferred: 50 mg/m² IM; repeat dose if hCG decline <15% between days 4 and 7.
  • Multi-dose and two-dose protocols available.
  • Monitor weekly quantitative hCG to zero.
  • Avoid alcohol, NSAIDs, folate supplements during treatment.
  • Contraindications: hemodynamic instability, rupture, anemia, severe organ dysfunction.

Surgical Management

  • Indications: rupture, hemodynamic instability, contraindications to MTX, large sac, fetal heartbeat, failed medical therapy.
  • Laparoscopy preferred.
  • Salpingectomy preferred for uncontrolled bleeding, recurrent ectopic, damaged tube, sterilization desire.
  • Salpingostomy considered to preserve fertility if contralateral tube compromised.
  • Postoperative hCG monitoring essential after salpingostomy.

Expectant Management

  • Selected stable patients with low and declining hCG (<1,500 mIU/mL) and no evidence of rupture.
  • Requires close monitoring with serial hCG and TVUS.

Other Management

  • Anti-D Rh immunoglobulin (50 µg) for Rh-negative women after surgery or significant bleeding.

Admission Criteria

  • Hemodynamic instability.
  • Suspected rupture.
  • Severe abdominal pain.
  • Inability to comply with outpatient follow-up.

Ongoing Care and Follow-Up

  • Weekly hCG monitoring until undetectable.
  • Pelvic ultrasound for persistent masses.
  • Delay pregnancy at least 3 months after MTX.
  • Pain management.
  • Liver and renal function monitoring if repeated MTX doses needed.

Prognosis

  • Fertility depends on preexisting tubal function and extent of damage.
  • 66% chance of future intrauterine pregnancy in women able to conceive.
  • Persistent infertility beyond 12 months warrants tubal evaluation.

Complications

  • Hemorrhage, hypovolemic shock.
  • Persistent trophoblastic tissue.
  • Infection.
  • Infertility.
  • Transfusion-related risks.
  • Disseminated intravascular coagulation (DIC) in massive hemorrhage.

Clinical Pearls

  • 97% of ectopics are tubal.
  • Always maintain high suspicion in pregnant patients with abdominal pain.
  • Serial hCG and TVUS are crucial for diagnosis.
  • Medical therapy with MTX effective in appropriate patients.
  • Surgical management essential for rupture or unstable patients.