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Ectopic Pregnancy

Background

Ectopic pregnancy refers to any pregnancy that occurs outside of the uterus. Approximately 98% of the time, this occurs in one of the fallopian tubes. Rarely, the fertilization can occur in the ovary, the abdomen or in the cervix. The pathology of this obstetric complication is simply that the fertilized ovum become lodged somewhere between the ovary and the uterus. This occurs in about 2 of every 100 pregnancies.

Ectopic pregnancies arise on the average in the 6th week of pregnancy. There is a failure for hCG to double every 48 hours, and the embryo is always termed unviable at this time.

These pregnancies are at high risk for rupture and hemorrhage. In fact, this is the most common cause of maternal death in the 1st trimester. Over 85% of these ectopic deaths are due to blood loss.

Signs and Symptoms

In early ectopic pregnancies, the patient is often asymptomatic or with mild pregnancy symptoms. However, once symptoms arise the classic triad includes adnexal pain, previous amenorrhea (history of pregnancy), and vaginal bleeding. The pain is described as sever, sharp, and sudden. It usually does not radiate, and is intermittent.

Vaginal bleeding is usually present, and on pelvic examination, the cervical os is most commonly closed with no loss of embryonic tissue.

Other symptoms include dizziness, SOB, nausea and vomiting, back pain, shoulder pain, tenesmus or even an urge to defecate. In 10% of cases, the patient presents in shock. This usually means there has been a rupture. With this there can be tachycardia, hypotension, hyperventilation or syncope.

The signs of an ectopic pregnancy may include a palpable adnexal mass, lower quadrant abdominal tenderness, peritoneal signs, uterine enlargement, lateral displacement of uterus, and positive orthostatic blood pressures or fever.

Diagnosis

Quantitative hCG will be lower than expected. If the hCG was to be taken over an extended period of time, levels would be rising slower than normal, or plateauing. This is important distinction from a spontaneous abortion which the hCG levels clearly are falling.

Ultrasound is extremely useful in diagnosing ectopic pregnancies. An empty uterus on trans-vaginal US with an hCG over 2000 mU/ml, or trans-abdominal US with an hCG over 6500 mU/ml, is considered practically diagnostic.

Laparoscopy is the sure way to diagnose ectopic pregnancy. This is also the surgical treatment of choice.

Progesterone levels can also be measured to help aid in diagnosis. In viable intrauterine pregnancies, the progesterone levels remain over 25 mg/ml for the first 8-10 weeks. If the progesterone level is below 5 mg/ml in this timeframe, this is diagnostic for some type of non-viable pregnancy.

Lastly, laboratory results will oftentimes show anemia and leukocytosis.

Differential Diagnosis

Differential diagnoses include other obstetric or gynecological conditions such as spontaneous abortion, molar pregnancy, ovarian cyst, or pelvic inflammatory disease. Non-gynecological differentials include acute appendicitis or urinary cal calculi.

Treatment

Conservative treatment in early pregnancies can include administering methotrexate. This is a reasonable option if the pregnancy is less than 2 cm and unruptured, the hCG is less than 10,000, there are no FHT’s present, and the patient is starting to fall.

If the patient does not meet these criteria, surgical laparoscopy or laparotomy is the treatment of choice. Dependent on the condition of the fallopian tube, it may or may not need a complete removal.

Prognosis

As with most medical conditions, if caught early enough, there is a great prognosis for ectopic pregnancy and the risk of rupture is fairly low. If rupture does occur however, hypovolemic shock and hemorrhage are the greatest dangers. There can also be consequences of infertility, infection, DIC and need for blood transfusions.

Risk Factors

Risk factors include previous ectopic pregnancy, pelvic inflammatory disease, previous tubal surgery, ruptured appendix, increased parity, endometriosis, or use of more invasive infertility treatments such as in vitro fertilization or embryo transfer. A history of previous ectopic pregnancy increases the risk by over 12%, but is not considered a contraindication for pregnancy.

 

 

 

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