Ectopic Pregnancy Overview

Ectopic Pregnancy

• Definition: A fertilized ovum implants outside the uterus.
• Common initial symptoms: Light vaginal bleeding and pelvic pain.
• Other symptoms: Shoulder pain, urge to have a bowel movement.
• Possible cause: Increased prevalence of chlamydia infections.
• High mortality rate: Second leading cause of maternal mortality in the first trimester.

Clinical Presentation

• Symptoms are often vague and subtle.
• Common symptoms: Abdominal pain (with or without vaginal bleeding/spotting), dizziness, and shoulder pain.
• Symptoms typically appear between 6 and 12 weeks of gestation.
• Early pregnancy signs (nausea, fatigue, breast tenderness) may be present.
• Pain may be generalized or localized to one side (unilateral) of the pelvis or abdomen.
• Shoulder pain can be a sign of a ruptured ectopic pregnancy.

Physical Exam and Diagnostics

• Obtain a complete medical history and physical exam.
• Monitor vital signs.
• Pelvic exam may reveal a bulging cul-de-sac (rupture possibility).
• Uterine enlargement may be present, but sometimes smaller than expected for gestational age.
• Check for abdominal tenderness.
• Assess for adnexal masses, involuntary guarding, and peritoneal signs.
• Diagnostics:
  • Rising hCG levels are a useful indicator of early ectopic pregnancy.
  • hCG levels below a certain threshold may suggest ectopic pregnancy.
  • Blood tests (e.g., CBC for anemia, blood type, Rh factor determination, serum progesterone) are important.
  • Transvaginal ultrasound (TVUS) is often used to visualize the location of a pregnancy when hCG is high enough (e.g. >1800 mIU/mL).

Differential Diagnoses

• Conditions to rule out include:
  • Appendicitis
  • Salpingitis
  • Cholecystitis
  • Pelvic Inflammatory Disease (PID)
  • Intrauterine pregnancy with inaccurate dates
  • Corpus luteum cyst
  • Gestational trophoblastic neoplasm
  • Incomplete or missed abortion
  • Endometriosis
  • Pelvic mass
  • Ureteral calculi
  • Adnexal torsion
  • Twisted cystic teratoma
  • Ruptured malignant ovarian tumor

Management

• Emergent referral to an Emergency Department (ED) is necessary for: positive hCG test, abdominal pain, and vaginal bleeding/rupture.
• Potential treatment options:
  • Pharmacotherapy (with guided ultrasound): Methotrexate or Potassium Chloride.
  • Folic acid antagonist.
  • Uterine immobilization.
  • Laparoscopic or laparotomy surgery (for ruptured ectopic pregnancy).

Complications

• Acute, massive bleeding is life-threatening.
• Misdiagnosis (occurring in 12% of cases) can lead to hemorrhage and death.
• Salpingectomy (removal of the fallopian tube) can affect future fertility, especially in patients with advanced age.
• Methotrexate can have adverse side effects including: mucositis, abdominal cramping, malaise, anaphylaxis, alopecia, depression, hepatotoxicity, pulmonary fibrosis, photosensitivity, and bone marrow depression (high doses).

Patient and Family Education

• Women need to be aware of the increased risk of reduced fertility and recurrent ectopic pregnancies.
• Condom use can help prevent infection and pelvic inflammatory disease (PID).
• During methotrexate therapy, women should temporarily refrain from sexual activity and avoid alcohol/folic-acid containing vitamins for at least 3 months.
• Increased abdominal pain 5-10 days after methotrexate warrants clinical evaluation due to possible tubal rupture.
• Methotrexate usage tends to have a high success rate for women with ectopic pregnancies; as 50% conceived within a year.

This quiz covers the definition, symptoms, and clinical presentation of ectopic pregnancy. Learn about its possible causes, early signs, and the importance of timely diagnosis and treatment. Test your knowledge on this critical aspect of maternal health.