Ectopic Pregnancies Flashcards
Sites of ectopic pregnancies
Fallopian tubes = 90%
Interstitial areas (corneal)= 2-4%
Cervix = 1%
- C-section scars/ ashermann syndrome area = 3%
most common chief complaints are abdominal pain and vaginal bleeding
Epidemiology of ectopic pregnancies
Ruptrered ectopic = 2.7% of all pregnancy related deaths
Rates of heterotopic pregnancy occurrence (twin pregnancy where one is normal and other is ectopic).
- 1:4000- 1:30000 of spontaneous pregnancies
- 1:100 in IVF pregnancies (most common)
Risk factors
- previous ectopic = most common (10%)
- damage to Fallopian tubes/ashermann syndrome
- history of PID
- prior tubal surgery
- smoking
- age > 35
- use of IUDs (copper)
3 main pathophysiology therapies for ectopic pregnancy
1) tubal obstruction
2) abnormal tubal motility
- hormone levels of IVF or OCP use
- IVF with damaged Fallopian tubes
* *this is believed to be why IVF rates of ectopic are so high**
3) chromosomal abnormalities of conceptus
Diagnosis of ectopic pregnancy
CC: abdominal pain and/or painful vaginal bleeding
History: usually says sharp pain with a history of spotting
PE: peritoneal signs, upper pelvic and lower abdominal tenderness
Ultrasound: FAST exam and transvaginal exam
Serum levels of:
- HCG
- CBC (Hgb of <6 = emergency)
- Rh factor (use of RhoGAM or not)
- *criteria**
1) ruptured ectopic = (+) pregnancy with free fluid in the pelvis = this until proven not
2) non-ruptured ectopic pregnancy:
- HCG > 2000 and nothing in the uterus
- there is NO intrauterine gestational sac (if this is present = no ectopic)
- embryonic heart motion in the adnexa is noted = ectopic 100%
note: that a adnexal mass doesnt mean ectopic by itself! Also double decidual reaction doesnt mean anything for ruling in or out
Pregnancy of unknown location work up
Get serial HCG 48 hrs apart from initial And ultrasound 1x a week
- if HCG doubles = definitely pregnant
Ectopic pregnancy management
Surgery from laparoscopy w/ salpingectomy or salpingostomy
Also add methotrexate usually
- MOA = chemotherapy that is a folate antagonist that affects actively proliferating tissues (prevents further growth of rapidly dividing tissues)
- requires values and criteria for methotrexate use = unruptured ectopic, clinically stable, normal liver/kidney and Bone marrow function and intrauterine pregnancy is ruled out
- *contraindications to methotrexate use**
- embryonic cardiac activity is present
- ectopic pregnancy mass > 4cm
- refusal to accept blood transfusion
Methotrexate protocols
Single dose
- 50 mg/m^2 @ day 1
- measure serum HCG at days 1/4/7
- treatment success = 15% decrease HCG between day 4-7 (continue measuring HCG weekly after this point until it is 0)
- if less than 15% = give second dose at day 7 or go to OR
Two dose
- methotrexate 50mg/m^2 @ day 1 and 4
- measure serum HCG at days 1/4/7
- treatment success = same as single dose
Multiple dose (usually reserved for cervical and interstitial ectopic)
- methotrexate 1mg/kg IM days 1/3/5/7
- folinic acid 0.1mg/kg IM days 2/4/6/8
- measure HCG levels on methotrexate days and need see a decrease from day 3-5 by 15%
Ruptured ectopic
Surgical emergency and needs laparoscopy + type and screen while getting to the OR
- *if you see a positive pregnancy test + free fluid in the pelvis = need laparoscopy regardless of vital signs**
- if unstable = do quick catch urine dipstick HCG while stabilizing (DONT do laparoscopy)
Follow up for ectopic pregnancy
HCG levels MUST be followed until 0
Need to talk about fertility
- methotrexate doesn’t affect this
- surgery however DOES
Also need to counsel patient about high risk of recurrence with future pregnancy
