Back-to-Basics: Ectopic Pregnancy

Mon, 08/31/2020 - 5:00am
Editor: 
Alison Jaworski, MD

ECTOPIC PREGNANCY

Valeria Wu, MD

 

Presents with: 

  • Abdominal pain (variable - can be lateralized to diffuse, mild to severe pain) 

  • Positive pregnancy test 

  • +/- amenorrhea or vaginal bleeding 

  • +/- tenderness of pelvic exam 

 

Risk factors:

  • Tubal ligation 

  • Prior ectopic 

  • PID 

  • Assisted fertility 

  • Smoker 

  • IUD

 

Background: 

  • Ampullary portion of fallopian tube common site of implantation 

  • 2% of pregnancy 

 

Workup:

  • Hbg, beta hcg quant, type and screen 

  • *** Ultrasound *** 

  • Beta HCG > 1500 without visualization of IUP on transvaginal or >6000 on transabdominal - ectopic until proven otherwise 

 

Treatment/Follow up: 

  • beta HCG < 1000 : can follow up with repeat in 48 hours with close OBGYN follow up if reliable 

  • RHOGAM for Rh neg women 

  • Methotrexate 50mg/m2 IM day 1 (with OBGYN consultation) - may require repeat dose day 7 

  • Contraindications: breastfeeding, immunocompromise, hepatic dysfunction, lung disease, cannot follow up, adnexal mass >3.5 cm, fetal heart tones, free fluid, beta hcg > 5000 

  • Will require close OBGYN follow up  

 

IF UNSTABLE:  

  • Hypotensive 

  • Altered 

  • Peritoneal 

  • May not be tachycardic with intraperitoneal bleed * relative bradycardia! 

DO: 

  • Two large bore IV 

  • Resuscitate, consider blood products 

  • Call OBGYN, patient will need OR 

 

REMEMBER: if you have a high suspicion, better to contact OBGYN sooner than later 

 

Consider other DDX: 

  • Threatened/missed/spontaneous abortion 

  • Molar pregnancy 

  • Heterotopic pregnancy 

  • Cervicitis/infection 

  • Implantation bleeding  

 

 

References:

  1. Centers for Disease Control and Prevention. Current trends ectopic pregnancy - United States, 1990-92. MMWR Morb Mortal Wkly Rep. 1995; 44:46-48. 
  2. Houry D and Keadey M. Complications in pregnancy part I: Early pregnancy. EBM. 2007; 9(6):1-28. 
  3. Jones R. Ectopic Pregnancy and Emergencies in The First 20 Weeks of Pregnancy. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed July 31, 2020.