Ectopic Pregnancy Overview

Ectopic Pregnancy

• Defined as pregnancy occurring outside the uterus
• Causes include implantation in the abdomen, fallopian tubes, cervix, ovary, or peritoneal surface.
• Symptoms are variable, commonly including abdominal pain, followed by amenorrhea and vaginal bleeding.
• Women rarely present with dizziness and syncope.
• Clinical signs encompass abdominal and adnexal tenderness, an adnexal mass, and varying uterine size.
• In over 70% of cases, the uterus is of normal size.
• A classic presentation includes abdominal pain, an adnexal mass, peritoneal irritation, and an enlarged uterus.

Differential Diagnosis

• Key differential diagnoses include acute salpingitis, torsion, gastroenteritis, threatened or incomplete abortion, and endometriosis.
• Pelvic inflammatory disease (PID) is a frequent condition confused with ectopic pregnancy.
• Up to 20% of patients with ectopic pregnancy may have temperatures up to 38°C (100.4°F).
• PID is less common in pregnancy (~less than 1% of the time).

Human Chorionic Gonadotropin (hCG)

• In normal intrauterine pregnancies, hCG levels increase by 66% every two days.
• Falling, plateauing, or failure to reach a predicted slope in hCG levels suggests an abnormal pregnancy.
• Serial hCG levels assist in assessing pregnancy viability and identifying the optimal time for ultrasonography.
• Following medical treatment, falling hCG levels help assess treatment effectiveness.

Ultrasound

• Real-time ultrasound examination of the pelvis can help localize a pregnancy.
• Findings depend significantly on gestational age and the type of sonographic approach.
• An interuterine gestational sac is typically visible by the fifth week.
• An embryo or fetal pole may be seen by the sixth week.
• Cardiac motion is often visible by the seventh week.
• Modern transvaginal ultrasound has improved diagnostic accuracy and allows earlier diagnosis of ectopic pregnancies.

Culdocentesis

• Used to determine intraperitoneal hemorrhage if ectopic pregnancy is suspected.
• Positive culdocentesis, indicating intraperitoneal bleeding, suggests a significant risk of ectopic pregnancy rupture.
• Culdocentesis typically involves locating the posterior fornix and inserting a needle to obtain fluid from the cul-de-sac.

Treatment

• Management of unstable patients focuses on hemodynamic support, including oxygen administration.
• Volume resuscitation is started immediately.
• Type-specific blood transfusions are administered as needed.
• Immediate gynecological consultation for surgical management is crucial.
• The risk of repeat ectopic pregnancies is elevated with increasing use of tubal conservation procedures.
• Treatment strategies for stable patients vary depending on the suspicion level and gestational age.

Surgical Treatment

• Laparoscopic surgery progressively replaces laparotomy for initial ectopic pregnancy treatment, offering benefits in terms of reduced morbidity and fertility preservation.
• Tubal conservation procedures, such as linear salpingectomy or segmental resection, can preserve fertility in some cases.
• Persistent ectopic pregnancies or ongoing trophoblast growth after incomplete removal complicate up to 20% of tubal operations.
• Salpingectomy may be required for persistent ectopic pregnancies that lead to hematomas.
• Systemic methotrexate represents a newer approach for treating ectopic pregnancies.

Systemic Methotrexate

• Methotrexate is widely used in treating gestational trophoblastic disease (GTD).
• Its mechanism involves inhibiting purine and pyrimidine synthesis, disrupting DNA synthesis, and thus cell multiplication.
• Stable patients with unruptured ectopic pregnancies less than 4 cm in diameter are eligible for methotrexate therapy.

Ovarian Torsion

• Ovarian torsion is a rare but serious condition involving twisting of the ovarian blood supply.
• The risk of ovarian torsion increases with ovarian enlargement.
• Torsion frequently leads to painful progressive anoxia, followed by eventual ovarian necrosis if not promptly treated
• Ovarian torsion can also accompany masses such as hydrosalpinx, pyosalpinx, and uterine leiomyomas(fibroids) .

Diagnosis of Ovarian Torsion

• Patients typically present with acute, unilateral, lower abdominal and/or pelvic pain.
• Associated symptoms include nausea, vomiting, fever, and abnormal genital bleeding.
• A unilateral adnexal mass is frequently found on examination.

Treatment of Ovarian Torsion

• Laparoscopic treatment, encompassing adnexal conservation or removal, is the preferred treatment approach.

Mittelschmerz

• Mittelschmerz refers to mild to moderate, unilateral lower abdominal pain that occurs around ovulation.
• It is often associated with ovarian follicle rupture.
• Mittelschmerz usually lasts less than a day.
• The pain is typically located midcycle and is characteristically unilateral.
• It may be accompanied by light midcycle endometrial spotting.

Diagnosis and Treatment of Mittelschmerz

• No definitive diagnostic tests are typically employed.
• Treatment usually involves analgesics and/or non-steroidal anti-inflammatory medications.

Abnormal Genital Bleeding

• Pathologic and traumatic causes must be systematically considered for abnormal genital bleeding (nonpregnancy).
• If trauma to the vulva or vagina is suspected, prompt patient stabilization and evaluation of the source of bleeding are crucial.
• Underlying pathologic conditions such as cervical carcinoma require further investigation and potential surgical intervention.

Hemorrhagic Corpus Luteum

• The corpus luteum, a temporary endocrine gland, typically persists up to 8 weeks of gestation.
• Rupture or hemorrhage into the corpus luteum may occur, resembling an ectopic pregnancy clinically.
• Ultrasound is crucial for distinguishing between a hemorrhagic corpus luteum and ectopic pregnancy.

Acute Rupture of Corpus Luteum Cyst

• Surgical intervention, including ovarian cystectomy, is usually necessary for acute rupture, especially in pregnant or nonpregnant cases.
• Outpatient management in presumed instances may be possible under certain circumstances, yet definitive patient observation is recommended.