Ectopic Pregnancy Case

Question 1

What lab test should you automatically do on females with abdominal pain?

Answer 1

pregnancy test unless post-hysterectomy

Question 2

How should you do this test?

Answer 2

a urine pregnancy test will miss very early ectopics, so do serum quantitative beta hCG

Question 3

What other lab tests would you consider?

Answer 3

CBC with differential and urinalysis
electrolytes, BUN and creatinine with vomiting or diarrhea
glucose and calcium to rule out DKA and hypercalcemia
liver function tests
amylase and lipase for upper abdominal pain

Question 4

What is the imaging study of choice for an ectopic pregnancy?

Answer 4

ultrasonography of the pelvis - transvaginal and transabdominal

Question 5

Which will be more sensitive for ectopic - transvaginal or transabdominal?

Answer 5

transvaginal

Question 6

What’s the best imaging for appendicitis?

Answer 6

CT of abdomen and pelvis

Question 7

When is ectopic pregnancy a medical emergency?

Answer 7

when it ruptures

Question 8

Where is the most common location for an ectopic pregnancy?

Answer 8

97% in the fallopian tubes (with 55% in ampulla, 25% in isthmus, and 17% in fimbria)

Question 9

Most women with ectopic pregnancies have no risk factors, but what are some?

Answer 9

previous PID (scarring)
history of prior ectopic
History of tubal surgery
conception after tubal ligation
use of fertility drugs or assisted reproductive technology
increasing age
smoking
endometriosis (scarring)
birth defects in fallopian tubes

Question 10

What is the frequency for ectopics?

Answer 10

2% of all pregnancies

increased 6-fold since 1970

Question 11

What are the common symptoms of ectopic pregnancy?

Answer 11

abdominal pain
amenorrhea
palpable adenxal mass
vaginal bleeding/spotting
maybe early pregnancy signs
nausea, vomiting
dizziness, syncope, hypovolemic shock if reuptured
tenesmus
low grade fever

Question 12

When does ectopic pregnancy occur in relation to LMP?

Answer 12

6-8 weeks after LMp

Question 13

What things should you do on exam for ectopic pregnancy?

Answer 13

vitals (may be normal even with intraperitoneal bleeding)

pelvic exam with bimanual and rectal

abdominal exam

Question 14

At what level of beta-hCG would you expect to be able to see an intrauterine pregnancy?

Answer 14

anything over 1500 mg

Question 15

How often should the serum hCG double?

Answer 15

every 48 hours

Question 16

What should you do for follow-up for a case in which you can’t rule out ectopic?

Answer 16

repeat the serum hCG and see if it doubled. if it did, repeat the ultrasound

if it didn’t, increase by over 66%, the pregnancy probably isn’t viable and a D&C should be done to look for chorionic villi

Question 17

What test used to be done before the advent of ultrasound?

Answer 17

culdocentesis - hemoperitoneum in the context of a positive pregnancy test is 99% predictive for a ruptured ectopic

Question 18

What is the primary treatment for an ectopic?

Answer 18

surgery - a tube sparing surgical technique like a laparoscopic salpingostomy is preferred

Question 19

What is the nonsurgical option and when is it viable?

Answer 19

methotrexate injection

small ectopic (less than 3-4 cm) with no fetal heart motion and hCG less than 5000

Question 20

What should you do if an ectopic or stponaneous abortion is confirmed in an Rh- woman?

Answer 20

give rhogam