Ectopic PregnancyCh 25

2009-2010 Academic YearMSIII Ob/Gyn Clerkship

Self-Directed Study

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Case Presentation

A 37 o G5P3013 with LMP 8 weeks ago presents to the ED with RLQ pain, nausea and vomiting, and vaginal spotting. The ED provider was concerned that the patient may have appendicitis because of her history, as well as her past surgical history significant for a tubal ligation. Initial lab work revealed a positive hCG.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Differential Diagnosis

GYN SAB Ruptured corpeus luteum cyst

PID Adnexal torsion

Degenerating fibroid

NON-GYN Appendicitis Pyelonephritis

Pancreatitis Peritonitis from other cause

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Risk Factors for Ectopic

Hx of tubal surgery Hx of STD’s (such as chlamydia) Hx of ART (assisted reproductive technology - IVF, clomid, etc)

Hx of ectopic (esp if conservatively managed without surgery)

Smoking IUD in place at time of conception

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Figure 25-1 Possible locations of ectopic pregnancy with spontaneous conception versus pregnancies that result from assisted reproductive technologies (ART) such as in vitro fertilization (IVF). Modified from Pisarska MD et al: Clin Obstet Gynecol 42:3, 1999.

Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)

© 2005 Elsevier

Adapted from Hacker, et al. 4th ed.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Incidence and Location

1 in 80 spontaneous pregnancies

Tubal 80% Ampullary 12% Isthmic 6% Fimbrial 2% Interstitial

Cervical, intraperitoneal, ovarian

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Locations of Etopics

Adapted from www.ectopicpregnancyfoundation.org

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Diagnosis

If HCG is above discriminatory value (1500-2000 depending on hospital), then US

US evaluation (Intra-uterine vs. extra) HCQ - 66% of pregnancies double in 48h Clinical Sx’s (bleeding, pain, hx of amenorrhea)

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Distribution curve of hCG in normal pregnancies with an ex of aDiscriminatory zone (DZ) in the shaded area. J Obstet Gynecol 152:299, 1985.

Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)

© 2005 Elsevier

Adapted from Hacker, et al. 4th ed.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Algorithm for diagnosis and treatment of ectopic in non-acute, stable patient.Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)

© 2005 Elsevier

Adapted from Hacker, et al. 4th ed.

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Treatment Options

Medical Management Methotrexate (See Table 25-1, pg 333)

Surgical Management Salpingostomy (incision in tube) Salpingectomy (removal of tube) Open abdominal incision or laparoscopy (depending on stability of patient)