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

 

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– 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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