Ectopic Pregnancy

Ch 25
2009-2010 Academic Year
MSIII Ob/Gyn Clerkship
Self-Directed Study
 Case Presentation
A 37 o G5P3013 with LMP 8 weeks
ago presents to the ED with RLQ
pain, nausea and vomiting, and
vaginal spotting. The ED
provider was concerned that the
patient may have appendicitis
because of her history, as well
as her past surgical history
significant for a tubal ligation.
Initial lab work revealed a
positive hCG.
2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
 Differential
Diagnosis
 GYN  NON-GYN
 SAB  Appendicitis
 Ruptured  Pyelonephrit
corpeus is
luteum cyst  Pancreatitis
 PID
 Peritonitis
 Adnexal from other
torsion cause
 Degenerating
fibroid
2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
 Risk Factors for
Ectopic
 Hx of tubal surgery
 Hx of STD’s (such as chlamydia)
 Hx of ART (assisted reproductive
technology - IVF, clomid, etc)
 Hx of ectopic (esp if
conservatively managed without
surgery)
 Smoking
 IUD in place at time of
conception

2009-2010 USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies
Adapted from Hacker, et al. 4th ed.

Figure 25-1 Possible locations of ectopic pregnancy with spontaneous conception versus pregnancies that result from assisted reproductive technologies (ART) such as
in vitro fertilization (IVF). Modified from Pisarska MD et al: Clin Obstet Gynecol 42:3, 1999.
Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)

2009-2010 USUHS MSIII Ob/Gyn © 2005 Elsevier

Clerkship Self Directed Studies

 Incidence and
Location
 1 in 80 spontaneous
pregnancies
 Tubal
 80% Ampullary
 12% Isthmic
 6% Fimbrial
 2% Interstitial
 Cervical, intraperitoneal,
ovarian
2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
 Locations of
Etopics

Adapted from www.ectopicpregnancyfoundation.org

2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
 Diagnosis

 If HCG is above discriminatory value (1500-

2000 depending on hospital), then US
 US evaluation (Intra-uterine vs. extra)
 HCQ - 66% of pregnancies double in 48h
 Clinical Sx’s (bleeding, pain, hx of
amenorrhea)

2009-2010 USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies
Adapted from Hacker, et al. 4th ed.

Distribution curve of hCG in normal pregnancies with an ex of a

Discriminatory zone (DZ) in the shaded area. J Obstet Gynecol 152:299, 1985.
Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)

2009-2010 USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies
© 2005 Elsevier
Adapted from Hacker, et al. 4th ed.

Algorithm for diagnosis and treatment of ectopic in non-acute, stable patient.

Downloaded from: StudentConsult (on 16 June 2009 03:48 AM)
2009-2010 USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
© 2005 Elsevier
 Treatment Options
 Medical Management
 Methotrexate (See Table 25-1, pg
333)
 Surgical Management
 Salpingostomy (incision in tube)
 Salpingectomy (removal of tube)
 Open abdominal incision or
laparoscopy (depending on
stability of patient)

2009-2010 USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies