Ectopic Pregnancy
An ectopic pregnancy occurs when fetal tissue implants outside of the uterus or attaches to an abnormal or scarred portion of the uterus. Ectopic pregnancies carry high rates of morbidity and mortality if not recognized and treated promptly. Ectopic pregnancies may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting. This activity will review the etiology of ectopic pregnancy and examine treatment approaches. This activity will outline the role of the interprofessional team in recognizing and treating patients with ectopic pregnancies. Ectopic pregnancy is a known complication of pregnancy that can carry a high rate of morbidity and mortality when not recognized and treated promptly. It is essential that providers maintain a high index of suspicion for an ectopic in their pregnant patients as they may present with pain, vaginal bleeding, or more vague complaints such as nausea and vomiting.
History and Physical
Women presenting with an ectopic pregnancy will often complain of pelvic pain; however, not all ectopic pregnancies manifest with pain. Women of childbearing age who complain of pelvic pain/discomfort, abdominal pain/discomfort, nausea/vomiting, syncope, lightheadedness, vaginal bleeding, etc. should merit consideration for the possibility of pregnancy. Providers need to identify when the patient’s last menstrual period occurred and whether they have monthly routine menstrual periods. If patients have missed their last period or have abnormal uterine bleeding, and are sexually active, then they may be pregnant and thus need further testing with a pregnancy test
Evaluation
Transvaginal ultrasound imaging is pivotal in diagnosing suspected ectopic pregnancy. Serial exams with transvaginal imaging, serum hCG level measurements, or both are necessary to confirm the diagnosis. The first marker of an intrauterine pregnancy on ultrasound is a small sac eccentrically located within the decidua.[2] Two rings of tissue will form around the sac thus terming it the “double decidual” sign.[2] The double decidual sign usually becomes visible during the 5th week of pregnancy seen on abdominal ultrasound imaging.[2] The yolk sac will become apparent at this time but will require transvaginal ultrasound imaging for identification.[2] An embryonic pole will become visible on transvaginal imaging at around six weeks of pregnancy.[2] Uterine fibroids or highly elevated body mass index can limit the accuracy of ultrasound imaging to identify an early intrauterine pregnancy
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Treatment / Management
Administration of intramuscular methotrexate or performance of laparoscopic surgery is safe and effective treatment modalities in hemodynamically stable women with a non-ruptured ectopic pregnancy. The decision of which modality to pursue is guided by the patient’s clinical picture, their laboratory findings, and radiologic imaging as well as the patient’s well-informed choice after having reviewed the risks and benefits with each procedure. Patients with relatively low hCG levels would benefit from the single-dose methotrexate protocol. Patients with higher hCG levels may necessitate two-dose regimens.
Prognosis
Patients with a relatively low beta hCG level will likely have a better prognosis regarding treatment success with single-dose methotrexate.[6] The further the ectopic pregnancy has advanced, the less likely single-dose methotrexate therapy will suffice. The patients that present in extremis or with hemodynamically instability have more risk of deterioration such as from hemorrhagic shock or other perioperative complications. Prognosis will thus hinge on early recognition and timely intervention.
Complications
Women who present early in pregnancy and have testing suggestive of an ectopic pregnancy would jeopardize the viability of an intrauterine pregnancy if given Methotrexate.[4] Women who receive the single-dose Methotrexate regimen are at high risk of treatment failure if the hCG level does not decrease by 15% from day 4 to day 7 thus prompting second-dose regimen.[6] Women presenting with vaginal bleeding and pelvic pain may be misdiagnosed as an abortion in progress if the ectopic pregnancy is at the cervical os. The patient may have a cervical ectopic pregnancy and would thus run the risk of hemorrhage and potential hemodynamic instability if a dilation and curettage are performed.[4] Complications from management extend to treatment failure, in that women may present with/or develop hemodynamic instability which can result in death despite early operative interventions.
N.B. The content provided on this blog page has been sourced from definitive and credible resources to ensure accuracy and reliability. We do not claim ownership of all the information shared.
N.B. The content provided on this blog page has been sourced from definitive and credible resources to ensure accuracy and reliability. We do not claim ownership of all the information shared.