overview and diagnosis of ectopic pregnancy c. kim 3.25.15
TRANSCRIPT
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OVERVIEW AND DIAGNOSIS OF ECTOPIC PREGNANCYC. KIM 3.25.15
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Learning Objectives
To describe the epidemiology of ectopic pregnancy To list risk factors for ectopic pregnancy To describe how an ectopic pregnancy is diagnosed Prerequisites:
NONE Closely related topics:
MEDICAL MANAGEMENT OF ECTOPIC PREGNANCYSURGICAL MANAGEMENT OF ECTOPIC PREGNANCY
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DEFINITION
An ectopic pregnancy is an EXTRAUTERINE pregnancy–one in which the BLASTOCYST implants anywhere other than the endometrial lining of the uterine cavity
95% of ectopic pregnancies implant in the fallopian tube1
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EPIDEMIOLOGYAccounts for 1-2% of pregnancies in U.S.Accounts for 9% of pregnancy-related
mortality (3rd most common cause)1
1/200,000 are bilateral2
Since 1970, the frequency has increased 4X3-4, however mortality has decreased 10X
Risk of mortality 3.4X higher in non-white women 2/2 issues with access to care3
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RISK FACTORSTubal factors1
prevalence of PID/STIs, especially chlamydia2 which may damage the tube
use of ART (artificial reproductive technologies)Prior pelvic surgery, especially surgery on fallopian
tube for previous ectopic, restorative purposes, or tubal sterilization
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RISK FACTORSOther risk factors:
Advanced maternal ageSmokingSTERILIZATION & IUDS
the risk of having an ectopic if a patient gets pregnant, HOWEVER, because they reduce the overall chance of even becoming pregnant to begin with… the overall risk of ectopic is decreased
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RISK FACTORS1-2 ODDS RATIO (95% CI)
Prior ectopic pregnancy 12.5 (7.5-20.9)
Prior tubal surgery 4.0 (2.6-6.1)
Smoking 20+ cigarettes/day 3.5 (1.4-8.6)
Confirmed PID via laparoscopy and/or positive test for C. trachomatis
3.4 (2.4-5.0)
3+ prior spontaneous miscarriages 3.0 (1.3-6.9)
40+ years of age 2.9 (1.4-6.1)
Prior medical or surgical abortion 2.8 (1.1-7.2)
12+ months of Infertility 2.6 (1.6-4.2)
5+ sexual partners over lifetime 1.6 (1.2-2.1)
Previous IUD-use 1.3 (1.0-1.8)
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CLINICAL PRESENTATION Approximately 50% of women diagnosed
with ectopic have no identifiable risk factors Classic symptoms include:
Abdominal pain Nausea / vomiting Missed period Vaginal bleeding
Other symptoms may include: syncope, dizziness, pregnancy symptoms, referred shoulder pain (due to blood in the abdomen irritating the diaphragm)
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DIFFERENTIAL DIAGNOSIS Tubal abortion Obstetric complications of an intrauterine pregnancy:
Threatened / Missed / Complete/ Incomplete abortionMolar pregnancy / Gestational trophoblastic neoplasia
Non-pregnant gynecologic causes:PID, follicular or corpus luteum cyst rupture,
endometriosis, ovarian torsion Common non-gynecologic causes:
Appendicitis, gastroenteritis, UTI, kidney stones,
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CLINICAL EVALUATION Physical exam
Can range from totally normal to hypovolemic shock and acute abdomen; abdominal/pelvic tenderness is found in 50-90% of patients
CMT (cervical motion tenderness) is also common Labs: CBC, b-HCG, Blood type and screen, +/- Progesterone
Beta HCG: The "discriminatory zone" of hCG is ~1,500–2,000 mIU/mL,
which when reached, is associated with the appearance of a normal singleton intrauterine gestation on TVUS1
Further, if the serum hCG is not rising > 53% over 48 hours, this confirms an abnormal pregnancy (99% sensitive)
Serum progesterone: > 20 normal IUP, 5-20 equivocal, <5 abnl pregnancy
MUCH less specific, rarely used
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DIAGNOSIS Imaging: Transvaginal ultrasound (TVUS)
If the hCG level is higher than the discriminatory zone, and the TVUS shows no IUP, ectopic pregnancy is likely (about 2/3)
An adnexal mass is found in ~1/3 of patients, however the absence of an adnexal mass DOES NOT rule out ectopic
Other concerning signs on TVUS include: free fluid in the pelvis or evidence of a pseudo-sac in the uterus
Other diagnostic tools Dilation & curettage - to check for products of conception (used in
cases of confirmed abnormal pregnancy or in cases where even if a threatened abortion of an early IUP was possible, that the pregnancy would NOT be desired)
Culdocentesis - using a needle to check for blood in the posterior cul-de-sac which would be present if the ectopic pregnancy ruptured
Rarely used, given modern ultrasound availability
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TVUS: WHAT DO YOU SEE?
#1(Wikipedia commons)
#2 #3
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TVUS: WHAT DO YOU SEE?
Ectopic in the adnexa
(Wikipedia commons)
Free fluid in posterior cul-de-sac
Ring of fire
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IMPORTANT LINKS
PRACTICE BULLETIN 94 – Medical Management of Ectopic Pregnancies
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OTHER SOURCES Barnhart KT. Ectopic Pregnancy. N Engl J Med. 2009; 261:379-387
Bouyer J, Coste J, Shojaei T, et al: Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol 157:185, 2003 [PubMed: 12543617]
Lipscomb, G. Obstetrics & Gynecology: 2010 - Volume 115 - Issue 3 – p 487-488
al-Awwad MM, al Daham N, Eseet JS: Spontaneous unruptured bilateral ectopic pregnancy: conservative tubal surgery. Obstet Gynecol Surv 54:543, 1999 [PubMed: 10481854]
Centers for Disease Control and Prevention: Ectopic pregnancy—United States, 1990-1992. MMWR Morb Mortal Wkly Rep 44:46, 1995
Van Den Eeden SK, Shan J, Bruce C, et al: Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol 105:1052, 2005
Ankum WM, Mol BW, Van der Veen F, et al: Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril 65:1093, 1996 [PubMed: 8641479]
Rajkhowa M, Glass MR, Rutherford AJ, et al: Trends in the incidence of ectopic pregnancy in England and Wales from 1966 to 1996. BJOG 107:369, 2000 [PubMed: 10740334]
Mol BW, Ankum WM, Bossuyt PM, et al: Contraception and the risk of ectopic pregnancy: a meta-analysis. Contraception 52:337, 1995 [PubMed: 8749596]
Buster JE, Pisarska MD: Medical management of ectopic pregnancy. Clin Obstet Gynecol 42:23, 1999 [PubMed: 10073296]
Doubilet et al. Diagnostic criteria for nonviable pregnancy in the early first trimester. N Engl J Med 2013;369:1443-51. DOI: 10.1056/NEJMra1302417