Ectopic Pregnancy Approach

Scenario: Patient coming with sudden severe left abdominal pain, pain in the left shoulder and PV bleeding. She had amenorrhea for 8 weeks. Her BhCG was 2500 mIU/mL. A transvaginal Ultrasound was done and showed absence intrauterine pregnancy.

– History – 

  • CC: if presents as abd pain -> use SOCRATES, if bleeding:
    • Onset: when? first time? Sudden\gradual? Continuous\intermittent? Getting better\worse?
    • Characteristics: amount? Color? Clots? Tissue? Smell?
  • Associated sx:
    • Constitutional: fever, chills, appetite?
    • Anemia: dizziness, syncope, headache, palpitations, SOB?
    • Vagina: vaginal bleeding (if yes, ask about anemia sx), clear fluid gush\leak, discharge, itching?
    • Urinary sx: dysuria, flank pain?
  • Obstetric Hx:
    • Gravida? Para? Abortions? Living?
      • If prev: mode of delivery? Fetal\maternal complications?
    • LMP?
    • Last US: when? Results? Singleton or multiple gestation?
    • Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?
  • Gynecological Hx:
    • Menstrual Hx: regular periods? Intermenstrual bleeding?
    • Contraception use, IUCD?
    • Gynecological procedures, IVF\induction of ovulation?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM\GDM, DLP)
      • Cardiac, thyroid, SLE
      • Hematological (anemia, APS)
      • Gyn (PID, fibroids, uterine anomalies)
    • Medications: abx, steroids, anticoagulants, folate, herbal
    • Surgery, hospitalization, trauma
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx
    • Diet, exercise

 


– Physical Exam –

  • WIPE, blah blah, chaperone
  • Vital signs: pulse, BP, temperature
  • General inspection: weight, distress, pallor
  • Chest: signs of pneumonia, cardiac diseases\murmurs
  • Abdomen:
    • Inspection: scars, contours, fetal movements, linea nigra, striae
    • Palpation: tenderness, guarding, rebound, uterus, masses, organs, contractions
    • Measure fundal height
    • Auscultation
  • Vaginal:
    • Discharge, bleeding, passage of tissue
    • Cervix: dilated, lacerations
    • Bimanual: motion tenderness, adnexal masses

 

– Differential Diagnosis –

  • Gynecological:
    • Ectopic pregnancy, ruptured?
    • Abortion
    • Molar pregnancy
    • Ovarian torsion\cyst
    • PID
  • Non-gynecological:
    • Appendicitis
    • Renal colic
    • Diverticulitis

 

– Investigations –

  • Quantitative serum B-hCG
  • Labs: CBC (WBC for infection, Hg for anemia, PT\PTT, blood type\cross match\Rh), chemistry (renal function, electrolyte), UA\midstream urine sample (to r\out UTI)
  • US: transvaginal > abdominal

 

– Management –

  • If unruptured:
    1. Methotrexate: single dose IM 50 mg, if:
      • B-hCG < 5000 mIU\mL
      • Pregnancy mass < 3.5 cm
      • Absent fetal cardiac activity
    2. Surgical laparoscopy\laparotomy -> salpigostromy, or salpingectomy if:
      • Pregnancy mass > 3.5
      • B-hCG > 5000 mIU\mL
      • Present fetal cardiac activity
      • Recurrent ectopic pregnancies
      • No future child bearing is planned
    3. Rhogam if Rh –
  • If ruptured \ hemodynamically unstable:
    1. Stabilize
    2. Immediate laparotomy
    3. Rhogam if Rh –

 

– Follow Up –

  • Weekly B-hCG levels until undetectable
  • Tell the pt it might recur in the other side

 


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