Ectopic

Question 1

Epidemiology

Answer 1

o 2% of all pregnancies (many are treated outpatient and not tracked)
o 2.7% of all pregnancy related deaths due to ruptured ectopic
o Up to 18% of 1st trimester vaginal bleeding/abdominal pain ED visits

Question 2

Etiology

Answer 2

o	Most common location is in the tube (90%)
o	Other locations (delay diagnosis/treatment- greater morbidity)
o	Abdomen  1%
o	Cervix 1%
o	Ovary 1-3%
o	C-section scar 1-3%
o	Heterotopic 1 in 4,000 to 30,000
o	Up to 1 in 100 in IVF

Question 3

Risk Factors

Answer 3

o 50% have no known risk factors
o Previous ectopic (10% chance of repeat)
o h/o 2 or more ectopic (risk up to 25%)
o Previous damage/trauma to fallopian tubes
o PID (ascending infection)
o Previous tubal surgery
o Use of ART (infertility tx related to tubal factor or multiple embryo transfer)
o H/O infertility
o Cigarette smoking
o Older than 35 yo
o Relative risk of up to 53% if using IUD

Question 4

Diagnosis

Answer 4

o Transvaginal US
o Adnexal mass with hypoechoic area separate from the ovary
 Positive predictive value of 80% (the mass may be paratubal cyst, endometrioma, corpus luteum, hydrosalpinx, bowel, etc)
 Beware of intrauterine pseudogestational sac
o Intrauterine gestational sac should be visible between 5 and 6 weeks gestation

o Serum quant bHCG level
o DO NOT USE TO DIAGNOSE – but it does help
o Concept of “discriminatory level”
 Should be conservatively high 3500 mIU/mL

o Signs of ruptured ectopic
o Hemodynamic instability or acute abdomen; urgent treatment