This document discusses ectopic pregnancy, which occurs when a fertilized egg implants and grows outside the uterus, usually in the fallopian tubes. Left untreated, an ectopic pregnancy can cause life-threatening complications due to internal bleeding. Common symptoms include abdominal pain, vaginal bleeding, and no menstrual period. Diagnosis involves blood tests to check human chorionic gonadotropin levels and ultrasounds to check for pregnancy location. Treatment options include medication with methotrexate or surgery depending on the situation. Most ectopic pregnancies occur in the fallopian tubes and early diagnosis and treatment are important to prevent serious health risks.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants and grows outside the uterus, usually in the fallopian tubes. Left untreated, an ectopic pregnancy can cause life-threatening complications due to internal bleeding. Common symptoms include abdominal pain, vaginal bleeding, and no menstrual period. Diagnosis involves blood tests to check human chorionic gonadotropin levels and ultrasounds to check for pregnancy location. Treatment options include medication with methotrexate or surgery depending on the situation. Most ectopic pregnancies occur in the fallopian tubes and early diagnosis and treatment are important to prevent serious health risks.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants and grows outside the uterus, usually in the fallopian tubes. Left untreated, an ectopic pregnancy can cause life-threatening complications due to internal bleeding. Common symptoms include abdominal pain, vaginal bleeding, and no menstrual period. Diagnosis involves blood tests to check human chorionic gonadotropin levels and ultrasounds to check for pregnancy location. Treatment options include medication with methotrexate or surgery depending on the situation. Most ectopic pregnancies occur in the fallopian tubes and early diagnosis and treatment are important to prevent serious health risks.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants and grows outside the uterus, usually in the fallopian tubes. Left untreated, an ectopic pregnancy can cause life-threatening complications due to internal bleeding. Common symptoms include abdominal pain, vaginal bleeding, and no menstrual period. Diagnosis involves blood tests to check human chorionic gonadotropin levels and ultrasounds to check for pregnancy location. Treatment options include medication with methotrexate or surgery depending on the situation. Most ectopic pregnancies occur in the fallopian tubes and early diagnosis and treatment are important to prevent serious health risks.
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[ECTOPIC PREGNANCY] 1
Ectopic pregnancy is the result of a flaw in human reproductive
physiology that allows the conceptus to implant and mature outside the endometrial cavity (see the image below), which ultimately ends in the death of the fetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation.
The following symptoms have also been reported:
Painful fetal movements (in the case of advanced abdominal pregnancy) Dizziness or weakness Fever Flulike symptoms Vomiting Syncope Cardiac arrest The presence of the following signs suggests a surgical emergency: Abdominal rigidity Involuntary guarding Severe tenderness Evidence of hypovolemic shock (eg, orthostatic blood pressure changes, tachycardia)
Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN.
The classic clinical triad of ectopic pregnancy is as follows: Abdominal pain Amenorrhea Vaginal bleeding Unfortunately, only about 50% of patients present with all 3 symptoms. Patients may present with other symptoms common to early pregnancy (eg, nausea, breast fullness).
Findings on pelvic examination may include the following:
The uterus may be slightly enlarged and soft Uterine or cervical motion tenderness may suggest peritoneal inflammation An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary Uterine contents may be present in the vagina, due to shedding of endometrial lining stimulated by an ectopic pregnancy Diagnosis Serum -HCG levels In a normal pregnancy, the -HCG level doubles every 48-72 hours until it reaches 10,000-20,000mIU/mL. In ectopic pregnancies, -HCG levels usually increase less. Mean serum -HCG levels are lower in ectopic pregnancies than in healthy pregnancies. No single serum -HCG level is diagnostic of an ectopic pregnancy. Serial serum -HCG levels are necessary to differentiate between normal and abnormal pregnancies and to monitor resolution of ectopic pregnancy once therapy has been initiated. The discriminatory zone of -HCG (ie, the level above which an imaging
[ECTOPIC PREGNANCY] 2
scan should reliably visualize a gestational sac within the uterus in a
normal intrauterine pregnancy) is as follows: 1500-1800 mIU/mL with transvaginal ultrasonography, but up to 2300 mIU/mL with multiple gestates [2] 6000-6500 mIU/mL with abdominal ultrasonography Absence of an intrauterine pregnancy on a scan when the -HCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion. Ultrasonography Ultrasonography is probably the most important tool for diagnosing an extrauterine pregnancy. Visualization of an intrauterine sac, with or without fetal cardiac activity, is often adequate to exclude ectopic pregnancy. [3] Transvaginal ultrasonography, or endovaginal ultrasonography, can be used to visualize an intrauterine pregnancy by 24 days postovulation or 38 days after the last menstrual period (about 1 week earlier than transabdominal ultrasonography). An empty uterus on endovaginal ultrasonographic images in patients with a serum -HCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proved otherwise. Color-flow Doppler ultrasonography improves the diagnostic sensitivity and specificity of transvaginal ultrasonography, especially in cases in which a gestational sac is questionable or absent. Laparoscopy Laparoscopy remains the criterion standard for diagnosis; however, its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies. Laparoscopy is indicated for patients who are in pain or hemodynamically unstable. See Workup for more detail.
Management Therapeutic options in ectopic pregnancy are as follows: Expectant management Methotrexate Surgery
Expectant management Candidates for successful expectant management should be asymptomatic and have no evidence of rupture or hemodynamic instability. Candidates should demonstrate objective evidence of resolution (eg, declining -HCG levels). Close follow-up and patient compliance are of paramount importance, as tubal rupture may occur despite low and declining serum levels of HCG. Methotrexate Methotrexate is the standard medical treatment for unruptured ectopic pregnancy. A single-dose IM injection is the more popular regimen. The ideal candidate should have the following: Hemodynamic stability No severe or persisting abdominal pain The ability to follow up multiple times Normal baseline liver and renal function test results Absolute contraindications to methotrexate therapy include the following: Existence of an intrauterine pregnancy Immunodeficiency Moderate to severe anemia, leukopenia, or thrombocytopenia Sensitivity to methotrexate Active pulmonary or peptic ulcer disease Clinically important hepatic or renal dysfunction Breastfeeding Evidence of tubal rupture Surgical treatment Laparoscopy has become the recommended surgical approach in most cases. Laparotomy is usually reserved for patients who are hemodynamically unstable or for patients with cornual ectopic pregnancies; it also is a preferred method for surgeons inexperienced in laparoscopy and in patients in whom a laparoscopic approach is difficult. Implantation sites The faulty implantation that occurs in ectopic pregnancy occurs
[ECTOPIC PREGNANCY] 3 because of a defect in the anatomy or normal function of either the fallopian tube (as can result from surgical or infectious scarring), the ovary (as can occur in women undergoing fertility treatments), or the uterus (as in cases of bicornuate uterus or cesarean delivery scar). Reflecting this, most ectopic pregnancies are located in the fallopian tube; the most common site is the ampullary portion of the tube, where over 80% of ectopic pregnancies occur. (See Etiology.) Nontubal ectopic pregnancies are a rare occurrence, with abdominal pregnancies accounting for 1.4% of ectopic pregnancies and ovarian and cervical sites accounting for 0.2% each. Some ectopic pregnancies
implant in the cervix (< 1%), in previous cesarean delivery scars, [7] or in a rudimentary uterine horn; although these may be technically in the uterus, they are not considered normal intrauterine pregnancies.[8] About 80% of ectopic pregnancies are found on the same side as the corpus luteum (the old, ruptured follicle), when present. [9] In the absence of modern prenatal care, abdominal pregnancies can present at an advanced stage (>28 wk) and have the potential for catastrophic rupture and bleeding.
