Ectopic Pregnancies

Question 1

Sites of ectopic pregnancies

Answer 1

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

Question 2

Epidemiology of ectopic pregnancies

Answer 2

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)

Question 3

3 main pathophysiology therapies for ectopic pregnancy

Answer 3

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

Question 4

Diagnosis of ectopic pregnancy

Answer 4

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

Question 5

Pregnancy of unknown location work up

Answer 5

Get serial HCG 48 hrs apart from initial And ultrasound 1x a week
- if HCG doubles = definitely pregnant

Question 6

Ectopic pregnancy management

Answer 6

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

Question 7

Methotrexate protocols

Answer 7

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%

Question 8

Ruptured ectopic

Answer 8

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)

Question 9

Follow up for ectopic pregnancy

Answer 9

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