Ectopic Pregnancy Overview

Ectopic Pregnancy

• Ectopic pregnancy is a pregnancy that occurs outside the uterus.
• It can develop in the fallopian tube, abdomen, cervix, ovary, or peritoneal surface.
• Symptoms are variable, but commonly include abdominal pain, amenorrhea, and vaginal bleeding.
• Over 70% of cases have a normal-sized uterus.
• Common symptoms include abdominal pain, adnexal mass, peritoneal irritation, and/or an enlarged uterus.
• Differential diagnoses include acute salpingitis, torsion, gastroenteritis, threatened or incomplete abortion, and endometriosis.
• Pelvic inflammatory disease (PID) is a common condition confused with ectopic pregnancy, but PID is rare during pregnancy (less than 1%).
• Up to 20% of patients with ectopic pregnancy may have temperatures up to 38°C (100.4°F).

Human Chorionic Gonadotropin (hCG)

• In a normal intrauterine pregnancy, hCG levels increase by 66% every 2 days.
• Falling, plateauing, or failing to reach a predicted slope in hCG levels indicates an abnormal pregnancy.
• Serial hCG levels help assess pregnancy viability and determine the optimal time for ultrasound.
• Post-treatment hCG levels are used to assess treatment effectiveness in cases of medical treatment using abortifacients or methotrexate.

Ultrasound

• Real-time ultrasound examination of the pelvis helps locate the pregnancy.
• Findings depend on the gestational age and approach used.
• An interuterine gestational sac can be detected in the fifth week.
• An embryonic/fetal pole may be seen by the sixth week.
• Embryonic motion (heartbeat) may be seen by the seventh week.
• Transvaginal ultrasound has improved diagnosis accuracy and decreased gestational age for diagnosis of an ectopic pregnancy.

Culdocentesis

• Culdocentesis may be used to detect intraperitoneal hemorrhage suspected in ectopic pregnancies.
• Cervical motion tenderness, and cul-de-sac fullness or bulging may accompany significant intraperitoneal hemorrhage.

Treatment

• Management of unstable ectopic pregnancies prioritizes hemodynamic support, oxygen administration, and volume resuscitation.
• Type-specific blood transfusions should be administered as needed.
• Immediate gynecological consultation for surgical management is essential.
• Tubal conservation procedures are more common, increasing the risk of repetitive ectopic pregnancies.
• Treatment of stable patients varies depending on suspicion of ectopic pregnancy and gestational age.

Surgical Treatment

• Operative laparoscopy is the preferred initial treatment for ectopic pregnancies, replacing laparotomy in most cases.
• Laparoscopy reduces morbidity and preserves fertility.
• Tubal conservation procedures (linear salpingectomy or segmental resection) aim to preserve fertility.
• Persistent ectopic pregnancies, or continued trophoblast growth after incomplete removal, occur in 5-20% of tubal operations and may require salpingectomy.
• Systemic methotrexate is a newer treatment option.

Medical Treatment (Systemic Methotrexate)

• Methotrexate inhibits spontaneous synthesis of purines and pyrimidines, interfering with DNA synthesis and cell multiplication.
• Used for unruptured ectopic pregnancies measuring less than 4 cm.

Ovarian Torsion

• Ovarian torsion occurs when the ovary twists on its pedicle, compromising blood supply.
• It is uncommon unless limited enlargement has occurred.
• Symptoms usually include sudden pain, progressive anoxia leading to possible gangrenous necrosis of ovary.

Diagnosis

• Patients often present with acute, severe, unilateral lower abdominal and pelvic pain, frequently with nausea and vomiting.
• Pelvic examination may reveal an adnexal mass.
• Fever, abnormal genital bleeding, and previous intermittent episodes are also possibilities.

Treatment (Ovarian Torsion)

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

Mittelschmerz

• Mittelschmerz is mid-cycle pain due to follicular fluid irritation of the periovarian visceral peritoneum during ovulation.
• Pain commonly occurs between cycle days 14-16 (28-33 cycle), and is unilateral in location, and has a mild to moderate severity, lasting commonly under 24 hours.

Diagnosis and Treatment (Mittelschmerz)

• No specific diagnostic tests exist.
• Treatment involves analgesics or non-steroidal anti-inflammatory agents.
• Tracking menstrual cycles is recommended to confirm the timing of ovulation.

Abnormal Genital Bleeding (Non-Pregnancy)

• Trauma, especially to the vulva and vagina, can cause profuse bleeding and hypotension.
• Uterine bleeding that doesn't involve trauma might have causes like invasive cervical carcinoma or cervix erosion/other pathological sources.
• In most cases, initial stabilization with intravenous fluids, a thorough pelvic examination, and potential anesthetics and surgical assistance are required.

Hemorrhagic Corpus Luteum

• The corpus luteum of pregnancy usually persists until the 8th week of gestation, frequently as a palpable 3-4 cm adnexal mass.
• Rupture of this cyst can occur and lead to clinical findings indistinguishable from ectopic pregnancy.
• An intrauterine pregnancy visualization using ultrasound will differentiate between these conditions.
• Corpus luteum cyst ruptures more commonly than ruptured corpus luteum of pregnancy.