Ectopic Pregnancy

Julio Espinosa, M.D.ALGIA

Pereira, Colombia

Ectopic Pregnancy

Diagnosis and Management of Ectopic Pregnancy

JOSHUA H. BARASH, MD; EDWARD M. BUCHANAN, MD; and CHRISTINA HILLSON, MD, Thomas Jefferson University,

Philadelphia, Pennsylvania Am Fam Physician. 2014 Jul 1;90(1):34-40.

Ectopic Pregnancy

• 1 – 2 % of all pregnancies• 9 % of pregnancy-related deaths in the US• 50 % reduction in mortality rates since 1980s

Risk Factors

• Conditions that damage the integrity of the tube and impair smooth muscle contractions and ciliary beating.

History

• Most common Sxs are 1st trimester bleeding and abdominal pain (unruptured)

• Clinical Hx should include:– Pregnancy dating – Onset and intensity of Sxs– Review of risk factors

Physical Therapy

• Assess for peritoneal signs:– Rebound & cervical motion tenderness (poss.

hemo-peritoneum)– Inspection of cervical os for POCs (Ectopic vs SAB)– Pathology (decidual cast vs POCs)

Imaging

• Trans-vaginal US• A GS containing a YS should be identified by

5.5 weeks GA• Hetero-topic pregnancy: 1 in 4000

spontaneous pregnancy• Diagnostic challenge: Pregnancy is not

identified

Laboratory Tests• B-hCG Discriminatory Level:– 1,500 – 2,000 IU/L– Not perfect: Viable IUP not detected by US reported

up to 4,300 IU/L.

• Serial B-hCG:– Most pregnancies (99 %) increase by 50 % in 48 hrs

• 1 % of viable IUP have slower rates of increase• 20 % of ectopics increase by 50 % in 48 hrs

– Monitor until undetectable. Ruptured ectopic have been documented at very low or falling B-hCG.

Laboratory Test

Laboratory Tests

• Blood Type and Rh status– Rh negative to receive Rh (D) immune globulin

(RhoGam)

Treatment

• Methotrexate vs. Open or Laparoscopic surgery vs. Expectant management.

• Medically unstable or hemorrhage Surgery• Choice should be based on patient preference• 2007 Cochrane review found no difference in

success rates between laparoscopic salpingostomy and medical treatment

Medical Treatment

• Cost effective & avoids risk of surgery and anesthesia

• Methotrexate:– Folic acid antagonist that inhibits DNA synthesis

and cell replication– Selectively kill cyto-trophoblasts (rapidly dividing

cells at the fallopian tube implantation site), body then resorbs.

Medical Treatment

• Patient selection is important• Predictors of treatment failure– GS larger than 3.5 cm– Presence of cardiac activity– Presence of blood in the peritoneum– High progesterone level– High initial B-hCG level• There is NO level at which medical management is

contraindicated!

Medical Treatment

Medical Treatment

• Contraindicated in those with immune system compromise, damage to organs that metabolize MTX, or conditions that could be exacerbated by treatment.

• CBC, Cr, LFTs needed!

Medical Treatment

• Regimens– Trials have involved single-dose, two-dose, and

multi-dose regimens. – Single Dose preferred

• Adverse Effects– GI effects• Rare:

– Severe neutropenia– Reversible alopecia– Pneumonitis

Clinical Recommendations

The End