Women's Health Chapter 144 Ectopic Pregnancy PDF

Women’s Health Chapter 144 ECTOPIC PREGNANCY Definition of Ectopic Pregnancy Occurs when a fertilized ovum implants anywhere outside of the uterus Often first warning sign is light vaginal bleeding and pelvic pain, Other signs may be shoulder pain or an urge to have a bowel movement May be due to...

Women’s Health Chapter 144 ECTOPIC PREGNANCY Definition of Ectopic Pregnancy Occurs when a fertilized ovum implants anywhere outside of the uterus Often first warning sign is light vaginal bleeding and pelvic pain, Other signs may be shoulder pain or an urge to have a bowel movement May be due to increased prevalence of chlamydia infections Mortality remains high. ◦ Second leading cause of maternal mortality and the leading cause of pregnancy-related death in the first trimester Clinical Presentation Symptoms can be vague and subacute. Most common symptoms: abdominal pain with/without vaginal bleeding or spotting, dizziness, and shoulder pain Symptoms generally appear between 6 and 12 weeks of gestation. Amenorrhea for 1 to 2 months and the usual early signs of pregnancy (nausea, fatigue, breast heaviness) are often part of the initial presentation. May have generalized or unilateral pelvic or abdominal pain Pain to the shoulder (ruptured ectopic sign) Physical Exam and Diagnostics Obtain a thorough history and physical exam. Postural vital signs Speculum examination ◦ (a bulging cul-de-sac, indicative of hemoperitoneum in rupture): uterine enlargement occurs in roughly one fourth of women with ectopic pregnancy, but its size may be less than expected according to dates Check for abdominal tenderness. Adnexal mass, involuntary guarding, and peritoneal signs Diagnostics ◦ The slope of a rising human chorionic gonadotropin (hCG) titer has been found to be a useful determinant of early ectopic pregnancy below the ultrasonographic discriminatory zone. ◦ CBC (anemia), blood type, and Rh determination and serum progesterone (marker of viable pregnancy, levels > 22 mean viable, and < 16 is a failing pregnancy, and < 5 indicates a nonviable pregnancy) ◦ Transvaginal US when hCG is > 1800  Differential Diagnosis Until proved otherwise, ectopic pregnancy must be considered in any woman of childbearing age with abdominal pain and bleeding (or both) Appendicitis Salpingitis Cholecystitis PID Intrauterine pregnancy with inaccurate dates Corpus luteum cyst Gestational trophoblastic neoplasm Incomplete or missed spontaneous abortion Endometriosis Pelvic mass Ureteral calculi Adnexal torsion Twisted cystic teratoma Ruptured malignant ovarian tumor Management Emergent referral (ED) for a positive test result for serum human chorionic gonadotropin (hCG), abdominal pain, and vaginal bleeding/ruptured EP (indicated ruptured ectopic pregnancy) Pharmacotherapy with guided US ◦ Folic acid antagonist ◦ Methotrexate or potassium chloride Uterine immobilization Surgical laparoscopy or laparotomy- only treatment choice for ruptured ectopic pregnancy Complications Acute, massive bleeding and immediate threat to life Misdiagnosis occurs in 12% can result in sudden death secondary to hemorrhage and infection Salpingectomy affecting future fertility Reduced fertility associated with advanced age post- surgery Methotrexate has adverse side effects, including mucositis, abdominal cramping and malaise. Anaphylaxis, alopecia, depression, hepatotoxicity, pulmonary fibrosis, photosensitivity, bone marrow depression with high doses. Patient and Family Education All women should be informed of subsequent risk of reduced fertility and recurrent ectopic pregnancy Condom use encourage to reduce likelihood of infection and PID Women receiving methotrexate therapy for unruptured ectopic pregnancy need to refrain from sexual activity and consumption of alcohol or vitamins containing folic acid until after resolution of the ectopic pregnancy, preferably at least 3 MONTHS, due to potential teratogenic effects of methotrexate. Increase in abdominal pain 5 to 10 days after methotrexate therapy warrants clinical evaluation due to possibility of tubal rupture. Good fertility rate reported for women who received methotrexate(50%+ conceived within 1 year).