Ectopic Pregnancy Diagnosis and Signs

Study Notes

50% of patients with ectopic pregnancy experience abdominal pain, vaginal bleeding, and amenorrhea.
Other potential signs include:
- Painful fetal movements (in advanced abdominal pregnancy)
- Dizziness or weakness
- Fever
- Flu-like symptoms
- Vomiting
- Syncope
- Cardiac arrest
Signs suggesting a surgical emergency include:
- Abdominal rigidity
- Involuntary guarding
- Severe tenderness
- Evidence of hypovolemic shock (orthostatic blood pressure changes, tachycardia)

Serial serum quantitative beta-hCG levels are used, with an expected increase of 33% in 48 hours if the initial level is 3,000 mIU/mL.
Ultrasound imaging is necessary to visually determine the location of the pregnancy.
Visualization of a gestational sac with a yolk sac or embryo on ultrasound is essential for confirming an intrauterine pregnancy.
An hCG discriminatory level of 3,500 mIU/mL indicates the potential for visualizing landmarks of an intrauterine pregnancy on ultrasound.

Medical management with intramuscular methotrexate is an option for hemodynamically stable women with a confirmed or suspected ectopic pregnancy, without rupture, and no contraindications.
Methotrexate is not FDA-approved for this use, but it is endorsed by ACOG.
Medical management is more cost-effective and avoids the risks of surgery and anesthesia.
hCG values should be less than 1,500 mIU/mL for methotrexate therapy to be effective.

Gestational hypertension: BP > 150/90 after 20 weeks of pregnancy, resolving within 12 weeks postpartum.
- Clinically asymptomatic.
- Elevated BP without proteinuria.
- Medications may be withheld, but hydralazine or labetalol are safe if treatment is needed.
Chronic hypertension: BP > 140/90 before 20 weeks of gestation, persisting for > 6 weeks postpartum.
- Symptoms include headache and visual symptoms if severe.
- Mild BP > 140/90, Severe > 180/110 without proteinuria.
- Monitor every 2-4 weeks, then weekly at 34-36 weeks and deliver at 39-40 weeks.
- Severe HTN (BP > 150/100): Labetalol or intermediate-acting/extended-release nifedipine. Oral hydralazine can be added if needed. Methyldopa is a safe alternative but less effective.
- Avoid ACE inhibitors and diuretics.

Treatment: Daily blood glucose monitoring after fasting overnight and after each meal.
- Review home glucose levels at each office visit.
- Fasting glucose > 105 mg/dL or 2-hour postprandial glucose > 120 mg/dL may require insulin.
- Insulin is the treatment of choice, aiming for fasting glucose < 95 mg/dL.
  - NPH/Regular insulin regimen: 2/3 in the morning and 1/3 in the evening.
- Glyburide (oral hypoglycemic) can be used initially, but it carries a higher risk of eclampsia.
Early delivery by c-section at 38 weeks if the child is macrosomic.
Good glucose control is defined as normal results on a 2-hour glucose tolerance test.

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