Ectopic Pregnancy

Michelle Schroeder, MD
Busitema University Faculty of Health Sciences
 Question 1

• How frequently does an ectopic pregnancy occur?

 Ectopic Pregnancy

• Implantation of fertilized ovum outside endometrial

cavity
• Occurs in 1.5- 2% of pregnancies

• Potentially life threatening

 Question 2

• Name 4 risk factors for ectopic pregnancies

 Risk Factors
• Pelvic inflammatory disease

• Prior tubal surgery

• Prior ectopic pregnancies

• Cigarette smoking

• Age >35

• Multiple lifetime sexual partners

• Use of assisted reproductive technology

• Edometriosis

• IUD
 Question 3
• What is the most common site of an ectopic?
Implantation Sites
 Question 4

• A 25yo F presents with severe abdominal pain over the

last 4 hours. She reports that she missed her period 2
weeks ago. On abdominal exam, she has tenderness in
the RLQ. On pelvic exam, there is dark red blood
present and the os is closed.

• What is in your differential diagnosis?

 Ectopic Triad

• Present in 50% of patients

• Pain
• Located in the pelvis
• May be diffuse or located to one side

• Amenorrhea

• Vaginal bleeding- scant, dark brown

• No specific pattern
 Ruptured ectopic

• Presents with signs of shock

• Hypotension
• Tachycardia

• Rebound tenderness

• Emergency!
 Question 5

• In the prior patient, what investigations should be done

to confirm your diagnosis?
 Step 1

• Confirm presence of pregnancy

• HCG
• Start with urine first, if positive and suspecting ectopic,
perform serum bHCG
• Wide range of normal levels in each week of pregnancy
 Step 2
• Evaluate hemodynamic stability

• If patient unstable- immediately take to theatre for

surgery
• Take vitals supine, and sitting/ standing to assess for
orthostatic hypotension

• Physical exam
• Abdomen- may be tender, distended, rebound/ guarding
• Complete pelvic exam

• Labs: CBC, Type and Crossmatch

 Step 3
Evaluate the location of the
pregnancy
Perform Transvaginal Ultrasound
(TVUS)
Look for gestational sac and
fetus
Heterogeneous fluid
collection in posterior cul de
sac could be sign of blood
 Question 6
• Below is the patient’s ultrasound. Where is the
pregnancy?
Ectopic pregnancy
Pregnancy of Unknown Location

• Discriminatory zone- serum hCG level at which a

pregnancy should be visualized in uterus if present
• Between 1500- 3500 IU

• Normal pregnancy
• hCG rises 66% in 48 hours

• If hCG is above the discriminatory zone and no

pregnancy seen on TVUS, pregnancy is extrauterine
 Following hCG
• Normal rise
• Reevaluate patient with TVUS once hCG reaches 3500

• hCG increasing but not normal

• Abnormal pregnancy- ectopic or inevitable Ab

• hCG decreasing
• Consistent with failed pregnancy
 Question 7

• After 48 hours the patient’s hCG increases from 3000

to 3850. An ultrasound is repeated and no intrauterine
gestation is found. What are her treatment options?
 Expectant Management-
Outcomes
• Rupture
• Hemorrhage, can be fatal
• Major cause of pregnacy-related mortality in the 1st
trimester

• Tubal abortion- expulsion of products of conception

through fimbriae
• May result in abdominal or ovarian ectopic pregnancy

• Spontaneous resolution- usually an option with

declining hCG
 Methotrexate
• Folic acid antagonist

• Inhibits DNA synthesis and cell reproduction

• Highly active proliferating cells (malignancy, trophoblasts, fetal
cells)

• Dose: 50mg/m2, single dose

• Multi-dose regimens also available

• Route of administration
• IV
• IM- most common
• Oral
• Direct local injection
 Methotrexate Candidates

• Hemodynamically stable

• No contraindications to methotrexate therapy

• hCG <5,000 mIU

• No fetal cardiac activity

• Willing and able to comply with post- treatment follow

up
 MTX Contraindications
• Abrnormalities in hematologic, renal or hepatic laporatory
invesitgations
• Renal and liver disease can slow metabolism
• Can cause bone marrow suppression

• Immunodeficiency

• Active pulmonary disease

• Peptic ulcer disease

• Breastfeeding

• Relative
• Gesational sac >3.5mm
 MTX follow up

• Check hCG on Day 1 of MTX administration

• Draw hCG on Day 4 and Day 7

• Decrease between Day 4 and 7 should be 15%

• After Day 7, repeat hCG weekly until level is

undetectable
 Question 8

• A 19yo patient presents to the hospital after syncope.

Two days ago, she received a dose of methotrexate for
suspected ectopic pregnancy. Blood pressure is 90/45
and HR is 126. What is the next step?
 Surgical Management
• Hemodynamically unstable

• Signs and symptoms of rupture

• Heterotopic pregnancy with coexisting viable IUP

• Contraindications to methotrexate

• Failed methotrexate
Salpingostomy
Salpingectomy
 Surgical options

• Laparoscopy
• Preferred method when available
• Minimally invasive

• Laparotomy
• More invasive
• May be less time to surgery