1. Ectopic Pregnancy Ch 25 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

2. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies 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.

3. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Differential Diagnosis  GYN  SAB  Ruptured corpeus luteum cyst  PID  Adnexal torsion  Degenerating fibroid  NON-GYN  Appendicitis  Pyelonephritis  Pancreatitis  Peritonitis from other cause

4. 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

5. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies 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) © 2005 Elsevier Adapted from Hacker, et al. 4th ed.

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

7. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Locations of Etopics Adapted from www.ectopicpregnancyfoundation.org

8. 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)

9. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies 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) © 2005 Elsevier Adapted from Hacker, et al. 4th ed.

10. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Algorithm for diagnosis and treatment of ectopic in non-acute, stable patient. Downloaded from: StudentConsult (on 16 June 2009 03:48 AM) © 2005 Elsevier Adapted from Hacker, et al. 4th ed.

11. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies 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)