Ectopic Pregnancy

Incidence 2% of all pregnancies 2% of all pregnancies 6% of maternal mortality 6% of maternal mortality 6 fold increase in ectopic 1970 to fold increase in ectopic 1970 to ectopics per 1000 pregancies, stable since ectopics per 1000 pregancies, stable since 1992

Risk Factors Prior PID especially chlamydia Prior PID especially chlamydia Prior ectopic pregnancy Prior ectopic pregnancy Prior tubal surgery Prior tubal surgery History of infertility History of infertility History of IUD usage History of IUD usage In vitro fertilization In vitro fertilization

Diagnostic Tools Clinical triad of delayed menes, pain, and abnormal bleeding Clinical triad of delayed menes, pain, and abnormal bleeding Ultrasound Ultrasound Beta HCG Beta HCG Progesterone Progesterone

Surgery Laparotomy verses Laparoscopy Laparotomy verses Laparoscopy Conservative verses radical surgery Conservative verses radical surgery

Methotrexate Single dose Single dose 50 mg/sq meter IM 50 mg/sq meter IM Multiple dose Multiple dose MTX 1 mg/kg on d 0,2,4,6 MTX 1 mg/kg on d 0,2,4,6 Leucovorin 0.1 mg/kg d 1,3,5,7 Leucovorin 0.1 mg/kg d 1,3,5,7

Side Effects Associated with Methotrexate Treatment Nausea Vomiting Stomatitis Diarrhea Gastric distress Dizziness Severe neutropenia (rare) Reversible alopecia (rare) Pneumonitis

Treatment effects Increase in abdominal pain (occurs in up to two thirds of patients) Increase in Beta HCG levels during first 1-3 days of treatment Vaginal bleeding or spotting

Signs of treatment failure and tubal rupture Significantly worsening abdominal pain, regardless of change in hCG levels Hemodynamic instability Levels of hCG that do not decline by at least 15% between day 4 and day 7 post injection Increasing or plateauing hCG levels after the first week of treatment

3/2 NJ is a 29 y/o GoPo complaining of no period PI: one month of intermittant low abd cramps Spotting on and off Gyn Hx: sexually active no birth control PE: Abdomen soft nontender Pelvic exam: no vaginal bleeding, Cx if closed, uterus is nontender, no adnexal mass or tenderness

Quant Beta HCG = 3633 Ultrasound: 1 cm gestational sac in Left Adenexa

3/3 Methotrexate 50 mg/sq m IM 3/6 (day 4) Quant = /9 (day 7) Quant = 5817 (3.3% decrease)

3/10 Methotrexate 50 mg/ sq m IM 3/13 (day 4) Quant = /16 (day 7) Quant = 2609 (54% decrease)

3/2 NJ is a 29 y/o GoPo complaining of no period PI: one month of intermittant low abd cramps Spotting on and off Gyn Hx: sexually active no birth control PE: Abdomen soft nontender Pelvic exam: no vaginal bleeding, Cx if closed, uterus is nontender, no adnexal mass or tenderness

Quant = 1500 Ultrasound show gestational sac in the uterus

3/16 CC: cramping continues on and off but the bleed is more like a menstral period Pelvic exam shows menstral blood in the vagina but the cervix is slightly dilated, uterus and adenexa are tender but no masses felt Ultrasound shows thickened endometrium with no gestational sac as seen 2 weeks ago

Quant = 4500

Path report shows chorionic villi