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Key Features

Essentials of Diagnosis

  • Amenorrhea or irregular bleeding and spotting

    • Pelvic pain, usually adnexal

    • Adnexal mass by clinical examination or ultrasound

    • Failure of serum level of human chorionic gonadotropin (hCG) to double every 48 h

  • No intrauterine pregnancy on transvaginal ultrasound with serum β-hCG of > 2000 milli-units/mL

General Considerations

  • Occurs in approximately 2% of first trimester pregnancies; about 98% of cases being tubal pregnancies

  • Implantation may also occur in the peritoneum or abdominal viscera, the ovary, and the cervix

  • Undiagnosed or undetected ectopic pregnancy is one of the most common causes of first-trimester maternal death in the United States

Demographics

  • Conditions that prevent or retard migration of the fertilized ovum can predispose to ectopic implantation

  • Specific risk factors

    • History of infertility

    • Pelvic inflammatory disease

    • Ruptured appendix

    • Prior tubal surgery

Clinical Findings

Symptoms and Signs

  • Sudden onset of severe, nonradiating, intermittent stabbing lower quadrant pain

  • Backache may be present during attacks

  • Shock in about 10%, often after pelvic examination

  • At least two-thirds of patients give a history of abnormal menstruation; many have been infertile

  • Blood may leak from the tubal ampulla over days

  • Persistent vaginal spotting is usually reported

  • A pelvic mass may be palpable

  • Abdominal distention and mild paralytic ileus are often present

Differential Diagnosis

  • Acute appendicitis

  • Intrauterine pregnancy (threatened abortion)

  • Pelvic inflammatory disease

  • Ruptured corpus luteum cyst or ovarian follicle

  • Urinary calculi

  • Tuboovarian abscess

  • Gestational trophoblastic neoplasia, eg, hydatidiform mole

  • Shock or sepsis due to other causes

Diagnosis

Laboratory Tests

  • Complete blood count may show anemia and slight leukocytosis

  • Serum β-hCG levels are lower than expected for a normal pregnancy of the same gestational age

  • Serum β-hCG levels may rise slowly or plateau rather than double every 48 h as in viable early pregnancy or fall as in spontaneous abortion

Imaging Studies

  • Transvaginal ultrasound may identify the ectopic pregnancy

  • An empty uterine cavity demonstrated by abdominal ultrasound with an hCG of 6500 milli-units/mL is highly suspicious

Diagnostic Procedures

  • Diagnosis should be suspected when postabortal tissue examination fails to reveal chorionic villi

  • Steps must be taken for immediate diagnosis, including prompt microscopic tissue examination, ultrasonography, and serial β-hCG titers every 48 hours

Treatment

Medications

  • Intramuscular methotrexate (50 mg/m2)

    • Acceptable for early ectopic pregnancies < 3.5 cm and unruptured, without active bleeding and no fetal heart tones

    • Absolutely contraindicated in an unstable patient

  • Iron supplementation may be necessary for anemia during convalescence

  • All Rh-negative patients should receive Rho(D) Ig (300 mcg)

Surgery

  • Laparoscopy is the surgical procedure of choice to both confirm ...

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