CASE PRESENTATION:

ECTOPIC PREGNANCY
Intern in charge: PGI Erick Rafael Anca
OBJECTIVES
 To present a case of a patient with left lower
quadrant pain
 To discuss the clinical features, diagnosis and
treatment of ectopic pregnancy
 To present a journal about management of ectopic
pregnancy
GENERAL DATA
 D.B.J.B, 28 years old, G2P1 (1001)
 Filipino, married, and an Iglesia ni Cristo
 Currently residing at San Nicolas Building, Emmaus
Talon V, Las Pinas City
 Date of Birth: October 15, 1990
 Admitted for the 1st time at our institution last
October 19, 2018
 HISTORY OF PRESENT ILLNESS
 (+) missed menses
 No hypogastric pain, vaginal bleeding, foul-smelling
10 vaginal discharge
DAYS PRIOR
 Pregnancy test kit – positive
TO
ADMISSION  1st prenatal check-up with a midwife
 Given Folic Acid and Multivitamins once a day
 HISTORY OF PRESENT ILLNESS
 (+) vaginal spotting, brownish, amounting
6
2-3, lightly soaked pantyliner
DAYS PRIOR  (+) dull pain, 4-5/10, on left lower
TO quadrant, radiating to left flank
ADMISSION
 Went back to the midwife
 Consideration at that time was Threatened
Abortion
 HISTORY OF PRESENT ILLNESS
 Given: Dydrogesterone (Duphaston) 10
6
mg/tab 1 tablet 3 times a day and
DAYS PRIOR Isoxsuprine HCl (Duvadilan) 10 mg/tab 1
TO tablet 3 times a day
ADMISSION
 For transvaginal ultrasound
 Follow up after 1 week
 HISTORY OF PRESENT ILLNESS
 Cessation of vaginal bleeding
 (+) persistence of steady, dull pain, 3-4/10,
on the left lower quadrant, non-radiating
INTERIM
 No limitation of activities of daily living
 HISTORY OF PRESENT ILLNESS
 Recurrence of brownish vaginal bleeding,
amounting to 1 moderately soaked regular pad

9 HOURS
 (+) left lower quadrant pain, now boring in
PRIOR TO character, radiating to the left thigh and lower
ADMISSION back
 Consult with midwife -> advised Transvaginal
Ultrasound
TRANSVAGINAL ULTRASOUND FINDINGS
 Normal sized uterus with thickened and fluid
filled endometrial cavity
 Moderate posterior cul-de-sac fluid with
heterogeneous complex structure in left ovary
 Normal cervix and right ovary.
 HISTORY OF PRESENT ILLNESS
 (+) persistence of vaginal spotting,
brownish in color
4 HOURS  (+) persistence of boring, 4-5/10, left lower
PRIOR TO quadrant pain, radiating to the left thigh
ADMISSION
and lower back
 Now with pallor and profuse sweating
 HISTORY OF PRESENT ILLNESS
 ER consult at a private hospital in Las
Pinas
4 HOURS  Assessment: Ectopic Pregnancy
PRIOR TO
ADMISSION  Plan: For pelvic laparotomy
 Referral to SJDH -> Admission
PAST MEDICAL HISTORY
 No hypertension
 No diabetes mellitus
 No bronchial asthma
 No thyroid/liver/kidney disease
 No allergies to foods/medications
 No previous surgeries
FAMILY HISTORY
 No hypertension
 No diabetes mellitus
 No bronchial asthma
 No thyroid/liver/kidney/heart diseases
 No cancer
PERSONAL SOCIAL HISTORY
 Unemployed
 Smoker – 2 pack-years
 Alcoholic drinker – occasional
MARITAL AND SEXUAL HISTORY
 Married for 7 years
 30 years old
 Construction worker
MARITAL AND SEXUAL HISTORY
 First sexual contact: 18 years old
 Number of sexual partner: 1
 Last sexual contact: 2 weeks prior to admission
 Denies post-coital bleeding
MENSTRUAL HISTORY
 Menarche: 12 years old
 Interval: regular (monthly)
 Duration: 3-4 days
 2 fully soaked regular pads
 (+) dysmenorrhea on day 2
 Last Menstrual Period: Sept. 3-7, 2018
 Previous Menstrual Period: Aug. 5-18, 2018
OBSTETRIC HISTORY
G2P1 (1001)

  Year AOG Gender Weight Manner Place Remarks

Home
delivery, No
G1 2009 Full Term Female Unrecalled NSD
attended by complications
a midwife
G2 Present Pregnancy

 Age of gestation: 6 weeks and 4 days

GYNECOLOGIC/CONTRACEPTIVE HISTORY
 Denies history of having of vulvar rashes, vaginal
pruritus and foul-smelling vaginal discharge
 Oral contraceptive pills – 2010, for 1 month
only
 Denies injectables nor condom use
 Does not practice natural family planning
method
REVIEW OF SYSTEMS
General No easy fatigability, no weight loss,
Integument (+) pallor, no jaundice, no rashes
HEENT No headache, no dizziness, no blurring
of vision, no excessive lacrimation, no
nasoaural discharge, no vertigo, no
tinnitus, no hoarseness, no dysphagia,
no sore throat
REVIEW OF SYSTEMS
Respiratory No cough, no dyspnea, no
hemoptysis
Cardiovascular No chest pain, no palpitations, no
paroxysmal nocturnal dyspnea, no
orthopnea
Gastrointestinal No anorexia, no diarrhea, no
constipation, no hematemesis, no
melena, no hematochezia
Genitourinary (+) left lower quadrant pain, no
hematuria, no dysuria, no
hypogastric pain, (+) vaginal
bleeding, no foul smelling discharge,
no genital pruritus
Endocrine No polydipsia, no polyuria, no heat
or cold intolerance
Extremities No edema, no myalgia, no
arthralgia, no cyanosis
PHYSICAL EXAMINATION
 GENERAL APPEARANCE: Awake, agitated,
ambulatory, not in respiratory distress, weak
looking
 VITAL SIGNS:
BP - 90/60 mmHg HR - 110 beats/min
RR - 20 cycles/min Temp – 37.1 degree Celsius
Weight – 50 kg Height – 157 cm BMI – 20.28 (Ideal)
PHYSICAL EXAMINATION
 INTEGUMENT: (+) pallor, no jaundice, no
cyanosis, no rashes, no erythema; good skin
turgor
 HEENT: Anicteric sclerae, slightly pale
palpebral conjunctiva, no naso-aural
discharge, moist pinkish gums and oral
mucosa, no cervical lymphadenopathies
PHYSICAL EXAMINATION
 CHEST AND LUNGS: Symmetrical chest
expansion, no retractions, clear breath sounds
 BREAST: Symmetrical, no lesions or
retractions, no nipple discharge, non-tender,
no palpable masses
 HEART: Adynamic precordium, tachycardic,
regular rhythm, no S3 or S4; no murmurs
PHYSICAL EXAMINATION
 ABDOMEN: Flat, (+) rigid, board-like abdomen,
(+) tenderness all over the quadrant, boring,
8-10/10 in severity
 EXTREMITIES: No deformities, no edema, no
joint tenderness/swelling, full and equal
peripheral pulses
PHYSICAL EXAMINATION
 PELVIC:
External genitalia – grossly normal
Speculum exam - cervix violaceous, smooth, minimal
brownish discharge
Internal exam - cervix firm, long and closed; (+)
cervical motion tenderness, fullness of posterior cul
de sac; uterus and adnexae cannot be assessed due
to guarding
ADMITTING DIAGNOSIS
G2P1 (1001)
ECTOPIC PREGNANCY 6 4/7 WEEKS AGE OF
GESTATION, LEFT, PROBABLY RUPTURED
PLAN
UPON ADMISSION (ER LEVEL)
 NPO
 IVF: D5LR 1L to run for 8 hours (right arm)
 Heplock (left arm)
 Diagnostics: CBC, BT-RH, pregnancy test
UPON ADMISSION (ER LEVEL)
 Therapeutics: Cefuroxime 1.5 grams SIVP ANST
now.
 Reserve 2 units fresh whole blood for possible
OR use.
 For pelvic laparotomy possible salpingectomy,
left
 10/19/18 (5:00
CBC PM) – ER level
Hgb 13.3
Hct 39.9 Pregnancy 10/19/18 (5:00
WBC 8.48 test PM) – ER level
Plt 198 HCG Positive
Seg 84.60 ↑
Lymph 11.60 ↓
Blood type O(+)
ER OR
INTRAOPERATIVE
OPERATING ROOM
 Pelvic examination under spinal anesthesia
FINDINGS
Patient
Cephalad

Right Left
Left fallopian tube

Caudad
 FINDINGS
Patient Patient
FINDINGS
Patient
Cephalad
Left ovary

Right ovary

Right Uterus
Left

Right fallopian tube

Caudad
0R RR
RECOVERY ROOM
S O A P
No headache BP: 90/70 HR: 80 RR: G2P1 (1011) Tubal NPO
No dizziness 20 T: 36.8 Pregnancy, ampullary, left, Post op CBC
No nausea Pink palpebral ruptured; Salpingectomy, D5LR 1L x8H
No vomiting conjunctivae left under spinal anesthesia Therapeutics:
No dyspnea Clear breath sounds -Paracetamol 600mg
No chest pain Normal rate, regular IV q6 x 4 doses
Tolerable post op site pain rhythm -Tramadol 50mg IV
Able to move both lower No active vaginal q8 prn x severe pain
extremities bleeding Monitor vital signs
UO: 100 cc/hr, clear every 15 minutes
 10/19/18 (7:05
CBC
PM) – Post-op
Hgb 10.1 ↓
Hct 30.1 ↓
WBC 7.10
Plt 148 ↓
Seg 86.00 ↑
Lymph 10.60 ↓
RR SRNU
COURSE IN THE WARDS
DAY 1 POST-OP
S O A P
(+) passage of BP: 90/60 HR: 79 G2P1 (1011) Tubal Clear liquids now then
flatus RR: 19 T: 36.6 Pregnancy, ampullary, diet as tolerated at
No bowel Pink palpebral left, ruptured; lunch
movement conjunctivae Salpingectomy, left IVF to consume
Minimal post- Clear breath under spinal IFC out
operative site pain sounds anesthesia Start oral meds:
No vaginal Normal rate, - Cefuroxime 500mg
bleeding regular rhythm BID
No headache, no Abdomen soft, - Mefenamic acid
dizziness, no normoactive 500mg Q6
dyspnea bowel sounds, May apply abdominal
  non-tender binder
  UO: 50-100cc/hr,  
clear via IFC
 COURSE IN THE WARDS
DAY 2 POST-OP
S O A P
(+) passage of flatus BP: 90/70 HR: 80 RR: G2P1 (1011) Tubal Diet progressed to DAT
(+) bowel movement 19 T: 36.7 Pregnancy, ampullary, left, Continue oral meds:
(+) freely voiding Pink palpebral ruptured; Salpingectomy, left - Cefuroxime 500mg BID
Minimal post-operative conjunctivae under spinal anesthesia - Mefenamic acid 500mg Q6
site pain Clear breath sounds Advised early ambulation
No vaginal bleeding Normal rate, regular and deep breathing exercise
No headache, no rhythm  
dizziness, no dyspnea Abdomen soft,
  normoactive bowel
  sounds, non-tender,
well coaptated surgical
wound, no discharge
UO: 50cc/hr, clear
COURSE IN THE WARDS
DAY 3 POST-OP
S O A P
(+) bowel BP: 90/60 HR: 78 G2P1 (1011) Tubal MGH
movement RR: 19 T: 36.1 Pregnancy, ampullary, Home meds:
(+) freely voiding Pink palpebral left, ruptured; - Cefuroxime 500mg
Minimal post- conjunctivae Salpingectomy, left BID to complete for 7
operative site pain Clear breath under spinal days
No vaginal sounds anesthesia - Mefenamic acid
bleeding Normal rate, 500mg Q6 as needed
No headache, no regular rhythm for pain
dizziness, no Abdomen soft, For follow up check up
dyspnea normoactive at OPD on October 29,
  bowel sounds, 2018
  non-tender
UO: 30-50 cc/hr,
clear
HISTOPATHOLOGIC DIAGNOSIS
TUBAL PREGNANCY
FINAL DIAGNOSIS
G2P1 (1011) TUBAL PREGNANCY, AMPULLARY,
LEFT, RUPTURED; SALPINGECTOMY, LEFT
UNDER SPINAL ANESTHESIA
CASE DISCUSSION
SALIENT FEATURES
SUBJECTIVE
PERTINENT POSITIVE PERTINENT NEGATIVE
 28 years old  No foul-smelling vaginal
 (+) missed menses discharge and genital
pruritus
 (+) vaginal spotting
 Left lower quadrant pain
 No febrile episodes,
dizziness, nausea and
 (+) pallor vomiting, dysuria
 Smoker – 2 pack years  No previous surgeries
 (+) OCP (unrecalled) use
for 1 month last 2010
OBJECTIVE
PERTINENT POSITIVE PERTINENT NEGATIVE
 Weak looking, tachycardic, (+) pallor
 Slightly pale palpebral conjunctiva
Not in respiratory
 Rigid, board-like abdomen with distress
guarding
 Speculum exam - cervix violaceous, Moist pinkish gums
smooth, minimal brownish discharge
 Internal exam - cervix firm, long and
and oral mucosa
closed; (+) cervical motion
tenderness, fullness of posterior cul Adynamic
de sac; uterus and adnexae cannot
be assessed due to guarding precordium, regular
rhythm
OBJECTIVE
PERTINENT POSITIVE PERTINENT NEGATIVE

 TVS: heterogeneous
complex structure in
left ovary, moderate
fluid in posterior cul
de sac
 HCG: Positive
DEFINITION
Occurs when the Patient
fertilized
ovum/developing
blastocyst
implants at a site
outside of the
endometrial
cavity.

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
EPIDEMIOLOGY
 Leading cause of pregnancy-related deaths
during the first trimester
 10% of all maternal deaths worldwide, and
0.01% to 0.03% in the Philippines.
 Locally, annual statistics revealed that cases
of ectopic pregnancy increased from 13% in
2005 to 17% in 2009.

June, 2011 Philippine Journal of Obstetrics & Gynecology Volume 35 (No. 2).
RISK FACTORS
 Salpingitis
 Endometriosis
 Tubal Surgery
 Hormonal imbalance/alterations
Smoker –
 Previous abortion
2 pack
 Abnormality in embryonic development
years
Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
SITES

Patient
Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
RUPTURE
Patient  Hemoperitoneum is nearly always
found in advanced ruptured ectopic
pregnancy
 Episodic pain before the final
perforation
 Historically, at the time of laparotomy
for a ruptured ectopic pregnancy,
about half of the women have less
than 500 mL of hemoperitoneum

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
DIAGNOSIS
 The patient manifested Most common
1. Abdominal pain signs and
2. Absence of menses symptoms of
and irregular vaginal ectopic pregnancy
bleeding
3. Abdominal and
adnexal tenderness
4. Tachycardia

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
DIAGNOSIS
 Diagnosis is facilitated by a qualitative/
quantitative assay for HCG and pelvic
ultrasonography (TVS)
TVS: Moderate
posterior cul-de-sac
fluid with Pregnancy 10/19/18 (5:00
test PM) – ER level
heterogeneous
HCG Positive
complex structure in
left ovary
Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
DIAGNOSIS
 Qualitative pregnancy test and TVS, in (+)
symptoms of rupture + hemodynamic severity,
can establish the diagnosis

 (+) HCG and (+) peritoneal fluid in ultrasound

→ (+) Ectopic Pregnancy

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
MANAGEMENT
 Medical management:  Surgical management:
Methotrexate use Laparoscopy,
Laparotomy,
Salpingectomy,
Salpingostomy

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
MANAGEMENT

Barash, J.H, Buchanan, E.M., Hillson, Christina., Diagnosis and Management of

Ectopic Pregnancy, American Family Physician, July 2014
MANAGEMENT
 Laparoscopy is the procedure of choice,
however, opted for laparotomy since there are
no available surgeons with experience to do
laparoscopy and the lack of necessary
equipments

Kho, R.M., Lobo, R.A., Ectopic Pregnancy, Comprehensive Gynecology, 7th Ed.
MANAGEMENT
 Regardless of the route, since it was ruptured,
salpingectomy was the necessary procedure to
be done

Jazayeri, A., Surgical Management of Ectopic Pregnancy, Medscape, 2015

MANAGEMENT
 Royal College of Obstetric and Gynecology
- Salpingectomy over salpingotomy in women
with tubal ectopic pregnancy and a healthy
contralateral fallopian tube

RCOG., Diagnosis and Management of Ectopic Pregnancy Guideline, November 2016

JOURNAL DISCUSSION
TITLE
Single-dose versus two-dose administration of
methotrexate for the treatment of ectopic
pregnancy: a randomized controlled trial

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
INTRODUCTION
 Hemodynamically stable patients with ectopic
pregnancies are commonly treated with
systemic methotrexate (Lipscomb et al., 2000).
 Three methotrexate protocols, fixed multi-
dose, single-dose and two-dose regimens,
have been reported for the treatment of
ectopic pregnancy (ACOG, 2008)

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
INTRODUCTION
 However, there is currently a lack of consensus
regarding which dosage regimen is optimal
(Hajenius et al., 2007).

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
STUDY DESIGN
 A randomized trial was conducted on 92
participants with tubal ectopic pregnancy,
between May 2013 and April 2015.

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
METHOD
 Patients diagnosed with tubal ectopic
pregnancy and who elected to undergo
systemic methotrexate treatment
 Randomly assigned to follow either the single-
dose (n=46) or two-dose protocol (n=46)

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
METHOD
 Primary outcome measure was treatment success
without surgical intervention
 Secondary outcome measures were the
1. incidence of methotrexate-associated side effects
2. b-hCG resolution time
3. cost of care received
4. treatment satisfaction

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
RESULT
 Success rates between the single-dose and
two-dose groups did not show a significant
difference [82.6 versus 87.0%; relative risk (RR)
0.95; 95% confidence interval (CI) 0.80–1.13]

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
RESULT
 Success rate in a subgroup of participants with
a pretreatment b-hCG level of.5000 mIU/ml
appeared to be higher in the two-dose group
than in the single-dose group (80.0 versus
58.8%)

 Difference was not statistically significant

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
RESULT
 No significant differences in methotrexate-
associated side effects, cost or treatment
satisfactionwere observed between the groups.

 The two-dose group required a lower number

of days for the b-hCG level to decrease to ,5
mIU/ml than the single-dose group (25.7+13.6
versus 31.9+14.1 days; P ¼ 0.025).
Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
RESULT
RESULT
DISCUSSION
 The two-dose protocol was proposed by
Barnhart et al. (2007) to combine the efficacy
of the fixed multi-dose protocol with the
convenience of the single-dose protocol.

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
DISCUSSION
 The two-dose protocol was proposed by
Barnhart et al. (2007) to combine the efficacy
of the fixed multi-dose protocol with the
convenience of the single-dose protocol.
DISCUSSION
 This is the first study to compare the success
rates of the single-dose and two-dose
methotrexate treatment protocols for ectopic
pregnancy with reatment satisfaction and
acceptability of these two protocols as part of
the parameters

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
CONCLUSION
 Single-dose protocol with the option to
elaborate to a second dose in the case of
treatment failure could stand as the treatment
for ectopic pregnancy.
 Single dose methotrexate protocol may be not
so appropriate for women with high levels of
b-hCG

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015
RECOMMENDATION
 Multicenter, randomized clinical trials with
larger sample sizes are warranted to validate
the results of this study.

Seok, J. S., Taejong, S., et al., Human Reproduction, Oxford Journals, Nov. 2015