Ectopic Pregnancy

Question 1

Where are 98% of ectopics located?

Answer 1

Fallopian tubes

Other 2% - cervix, ovary, c-section scar

Question 2

What are signs and symptoms of an ectopic pregnancy?

Answer 2

a. Missed menstrual period
b. Vaginal bleeding
c. Abdominal discomfort
d. Early pregnancy symptoms
e. Signs of rupture

Question 3

What are the signs of rupture?

Answer 3

Hypotension

Pallor

Nausea

Shoulder pain

Question 4

What are risk factors for ectopic pregnancy?

Answer 4

a. Previous ectopic (15% recurrence risk)
b. Tubal surgery
c. Previous STD/PID, multiple sex partners
d. IUD (LNG-IUD is bigger risk)
e. Infertility/IVF
g. Smoking (impairs cilia function)

Question 5

What is the discriminatory zone

Answer 5

Serum HCG level above which you should see a gestational sac on transvaginal ultrasound if its an IUP

1500 - 2000

Question 6

What is your plan of action if:

Transvaginal ultrasound = + sac
Serum HCG value = > than the discriminatory zone

Answer 6

Normal IUP

Question 7

What is your plan of action if:

Transvaginal ultrasound = absent sac
Serum HCG value = < than the discriminatory zone

Answer 7

Expectant management:

• could be too early to visualize sac or could be ectopic
• follow as long as hemodynamically stable
• follow serum HCG q 48 hours

Question 8

What is your plan of action if:

Transvaginal ultrasound = + sac
Serum HCG value = < than the discriminatory zone

Answer 8

SAB, failed IUP

• should see gradual decrease in serum HCG (do q 48 hours)
• can take up to 6 weeks for HCG to go down to normal

Question 9

What is your plan of action if:

Transvaginal ultrasound = absent sac
Serum HCG value = > than the discriminatory zone

Answer 9

Ectopic

• if hemodynamically stable, can repeat HCG in 48 hours
• potentially a twin pregnancy?

Question 10

What is a heterotopic pregnancy?

Answer 10

Both an IUP and an ectopic

*very rare, can happen with IVF

Question 11

What is the medical treatment for ectopic and what are the criteria to use it?

Answer 11

Methotrexate - folic acid antagonist that inhibits DNA synthesis. Chemotherapeutic drug

• given as an IM injection
• may need 2-3 doses to work, or surgery

Criteria to use methotrexate:

• Hemodynamically stable
• No renal or hepatic disorders
• Starting HCG < 5,000
• No fetal cardiac activity

Question 12

What are the types of surgical management for ectopic pregnancy?

Answer 12

Salpingectomy - remove affected tube

Salpinostomy - dissecting the ectopic pregnancy only, tubal sparing

Question 13

When does HCG peak?

Answer 13

8 - 10 weeks

Question 14

How often does HCG double at first?

Answer 14

q 48 hours goes up 53 - 66%