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Ectopic Pregnancy, Emergency Medicine

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Ectopic Pregnancy, Emergency Medicine

Basics

Description

Classic triad of amenorrhea, vaginal bleeding, and abdominal pain are present in only 15% of women with ectopic pregnancies:

Cautions: Female patients of childbearing age presenting in shock may have unrecognized ruptured ectopic pregnancy

Methotrexate: Initiated only in conjunction with obstetric consultant and close follow-up:

Phone consultation (at a minimum) with OB/GYN is essential when discharging a possible ectopic pregnancy

All patients with positive pregnancy tests and unconfirmed IUP must be followed by an OB/GYN

  • Implantation of fertilized ovum outside of uterus:Most commonly fallopian tube (93-97%)
  • Abdominal and peritoneal implantations:Associated with higher morbidityDifficulty in diagnosisTendency to bleed
  • Occurs in 2-2.6% of pregnancies
  • Accounts for 6% of all maternal deaths (leading cause of 1st-trimester pregnancy-related death)
  • 60% of women with ectopic pregnancy are subsequently able to have a normal pregnancy
  • Most commonly fallopian tube (93-97%)
  • Associated with higher morbidity
  • Difficulty in diagnosis
  • Tendency to bleed

Etiology

  • Risk factors include:Woman >35 yr oldAfrican AmericanPrevious fallopian tube damage from infections, such as pelvic inflammatory disease (PID)Previous tubal surgery (i.e., tubal ligation)Previous ectopic pregnancyIntrauterine device (IUD) use:25-50% of pregnancies with IUD are ectopicDiethylstilbestrol (DES) exposureIn vitro fertilizationsBeing a current smoker
  • More than half of women with ectopic pregnancies have no risk factors
  • Woman >35 yr old
  • African American
  • Previous fallopian tube damage from infections, such as pelvic inflammatory disease (PID)
  • Previous tubal surgery (i.e., tubal ligation)
  • Previous ectopic pregnancy
  • Intrauterine device (IUD) use:25-50% of pregnancies with IUD are ectopic
  • Diethylstilbestrol (DES) exposure
  • In vitro fertilizations
  • Being a current smoker
  • 25-50% of pregnancies with IUD are ectopic

Diagnosis

Signs and Symptoms

  • Amenorrhea (75-95%)
  • Abdominal pain (80-100%):Frequently unilateral
  • Abnormal vaginal bleeding (50-80%)
  • Symptoms of pregnancy (10-25%)
  • Orthostatic hypotension, dizziness, and syncope (5-35%)
  • Abdominal tenderness (55-95%)
  • Adnexal tenderness (75-90%)
  • Adnexal mass (35-50%)
  • Cervical motion tenderness (43%)
  • Frequently unilateral
  • Last menstrual period (LMP):Majority of ectopics present 5-8 wk after LMP.
  • Gestation and parity history
  • Vaginal bleeding
  • Location, nature, and severity of pain
  • History of pelvic surgery, prior ectopic, IUD
  • History of fertility treatments
  • Majority of ectopics present 5-8 wk after LMP.
  • Evaluate for signs of peritoneal irritation
  • Pelvic exam:Note uterine sizeAdnexal size, massAdnexal tendernessPresence of tissue in vaginal vaultCervical motion tendernessCervical OS open or closed
  • Note uterine size
  • Adnexal size, mass
  • Adnexal tenderness
  • Presence of tissue in vaginal vault
  • Cervical motion tenderness
  • Cervical OS open or closed

Essential Workup

  • Pregnancy testing:Women of potential childbearing age with vaginal bleeding or abdominal pain must have urine or serum pregnancy testInclude testing of patients with history of recent elective or spontaneous abortion, tubal ligations, or IUD useQuantitative β-human chorionic gonadotropin (β-hCG) in patients with positive qualitative test
  • Vital signs unstable:2 large-bore IVsType and cross-match, hemoglobin (Hg)/hematocrit (Hct)Bedside ultrasound (US), if immediately available, simultaneous with resuscitation (transvaginal preferred)Consult obstetrics/gynecology (OB/GYN) and prepare for immediate surgical intervention
  • Vital signs stable:Rapid Hg/Hct determinationType and RhUS (transvaginal preferred)
  • Women of potential childbearing age with vaginal bleeding or abdominal pain must have urine or serum pregnancy test
  • Include testing of patients with history of recent elective or spontaneous abortion, tubal ligations, or IUD use
  • Quantitative β-human chorionic gonadotropin (β-hCG) in patients with positive qualitative test
  • 2 large-bore IVs
  • Type and cross-match, hemoglobin (Hg)/hematocrit (Hct)
  • Bedside ultrasound (US), if immediately available, simultaneous with resuscitation (transvaginal preferred)
  • Consult obstetrics/gynecology (OB/GYN) and prepare for immediate surgical intervention
  • Rapid Hg/Hct determination
  • Type and Rh
  • US (transvaginal preferred)

Diagnosis Tests & Interpretation

  • Urine pregnancy tests can detect β-hCG levels of 25-50 mIU/L
  • Serum can detect β-hCG levels of 25 mIU/L
  • Quantitative serum β-hCG; for diagnosis and follow-up:Doubles every 2 days in normal early pregnancy (early pregnancy <10,000 β-hCG mIU/L, 8 days-7 wk)β-hCG increases less in ectopic pregnancyCorrelation with vaginal US increases predictive value
  • Doubles every 2 days in normal early pregnancy (early pregnancy <10,000 β-hCG mIU/L, 8 days-7 wk)
  • β-hCG increases less in ectopic pregnancy
  • Correlation with vaginal US increases predictive value
  • Ultrasonographic evidence of IUP makes ectopic pregnancy less likely:Heterotopic pregnancies are possible
  • Positive IUP is indicated by double-ringed gestational sac, yolk sac, or fetal pole, and heartbeat seen in uterus
  • Transvaginal US; visualization of gestational sac at 5 wk, cardiac activity at 6.5 wk
  • Transabdominal US; visualization of gestational sac at 5-6 wk, cardiac activity at 8 wk
  • Complex adnexal mass and fluid in cul-de-sac seen in 22% of ectopics and has 94% positive predictive value when present
  • Positive pregnancy test with no confirmed IUP and fluid in pelvis; high risk for bleeding ectopic pregnancy
  • Heterotopic pregnancies are possible
  • US in conjunction with quantitative β-hCG
  • Patients with β-hCG levels >6,500 mIU/L and no intrauterine gestational sac seen on US have 100% chance of having ectopic pregnancy
  • Patients with β-hCG levels >6,500 mIU/L with intrauterine gestational sacs present have 94% chance of having normal pregnancy
  • Patients with β-hCG <2,000 mIU/L are too early to have gestational sac seen by abdominal US and thus cannot be ruled out for ectopic pregnancy
  • Patients with β-hCG >2,000 and <6,500 mIU/L should have IUP visualized on transvaginal US; suspect ectopic pregnancy if IUP is absentDiscriminatory hCG value for transvaginal US is between 1,500 and 3,000 mIU/mL
  • Culdocentesis to evaluate for intraperitoneal blood if US is unavailable
  • Discriminatory hCG value for transvaginal US is between 1,500 and 3,000 mIU/mL

Differential Diagnosis

  • Positive pregnancy test with vaginal bleeding:Spontaneous abortionCervicitisTrauma
  • Positive pregnancy test with no evidence of IUP:Completed spontaneous abortionEarly threatened abortion
  • Positive pregnancy test with evidence of IUP, abdominal pain, or adnexal tenderness:Septic abortionThreatened abortionRuptured corpus luteal or ovarian cystOvarian torsionUTINephrolithiasisGastroenteritisAppendicitisHeterotopic pregnancy (IUP + ectopic)PID
  • Spontaneous abortion
  • Cervicitis
  • Trauma
  • Completed spontaneous abortion
  • Early threatened abortion
  • Septic abortion
  • Threatened abortion
  • Ruptured corpus luteal or ovarian cyst
  • Ovarian torsion
  • UTI
  • Nephrolithiasis
  • Gastroenteritis
  • Appendicitis
  • Heterotopic pregnancy (IUP + ectopic)
  • PID

Treatment

Pre-Hospital

Initial Stabilization/Therapy

  • Vital signs unstable:Airway management, resuscitate as neededFluid therapy with 2 large-bore IVs, oxygen, and monitorType specific, or O-negative blood if hypotensive after initial fluid bolusConsult gynecology and transport to OR immediately for surgery
  • Vital signs stable:Evidence of ectopic pregnancy on US:Obstetric-gynecologic evaluation for surgery vs. outpatient methotrexate treatmentFor patients in whom future fertility is desired, methotrexate is the best option; otherwise surgery is the definitive treatmentNo evidence of ectopic pregnancy (pregnancy of unknown location [PUL]: Early IUP vs. early ectopic):Desired pregnancy: Serial β-hCG every 48 hr in stable, reliable patients and in conjunction with obstetricianUndesired pregnancy: Dilation and curettage to evacuate uterus and confirm presence of products of conception
  • Airway management, resuscitate as needed
  • Fluid therapy with 2 large-bore IVs, oxygen, and monitor
  • Type specific, or O-negative blood if hypotensive after initial fluid bolus
  • Consult gynecology and transport to OR immediately for surgery
  • Evidence of ectopic pregnancy on US:Obstetric-gynecologic evaluation for surgery vs. outpatient methotrexate treatmentFor patients in whom future fertility is desired, methotrexate is the best option; otherwise surgery is the definitive treatment
  • No evidence of ectopic pregnancy (pregnancy of unknown location [PUL]: Early IUP vs. early ectopic):Desired pregnancy: Serial β-hCG every 48 hr in stable, reliable patients and in conjunction with obstetricianUndesired pregnancy: Dilation and curettage to evacuate uterus and confirm presence of products of conception
  • Obstetric-gynecologic evaluation for surgery vs. outpatient methotrexate treatment
  • For patients in whom future fertility is desired, methotrexate is the best option; otherwise surgery is the definitive treatment
  • Desired pregnancy: Serial β-hCG every 48 hr in stable, reliable patients and in conjunction with obstetrician
  • Undesired pregnancy: Dilation and curettage to evacuate uterus and confirm presence of products of conception

Ed Treatment/Procedures

  • Reliable patients with unruptured ectopic pregnancies <3.5 cm
  • β-hCG levels <6,000-15,000
  • Contraindications:Breast-feedingImmunodeficiencyPre-existing blood dyscrasiaClinically significant anemiaKnown sensitivity to methotrexateActive pulmonary diseasePeptic ulcer diseaseHepatic dysfunctionRenal dysfunctionAlcoholismAlcoholic liver diseaseEctopic mass >3.5 cm (relative contraindication)Embryonic cardiac motion (relative contraindication)
  • Most common dosing, single dose (50 mg/m2); serial β-hCG on days 2, 4, and 7If <25% decline in β-hCG from day of 1st injection, 2nd dose is given
  • Multidose treatment is associated with less treatment failure
  • Common side effects:Worsening abdominal painNausea, vomiting, and diarrhea
  • Worsening abdominal pain usually occurs 3-7 days after methotrexate initiation.These are usually tubal miscarriagesFollow-up USs are essential to rule out ectopic rupture
  • Most common complication, tubal rupture in 4%
  • Factors associated with methotrexate treatment failure:Initial hCG >5,000 mIU (5,000-9,999 mIU/mL-13% failure rate, >15,000 mIU/mL failure rate as high as 32%)Moderate to large free peritoneal fluid on USPresence of fetal cardiac activityPretreatment increase in serum hCG level of more than 50% over a 48 hr period
  • Breast-feeding
  • Immunodeficiency
  • Pre-existing blood dyscrasia
  • Clinically significant anemia
  • Known sensitivity to methotrexate
  • Active pulmonary disease
  • Peptic ulcer disease
  • Hepatic dysfunction
  • Renal dysfunction
  • Alcoholism
  • Alcoholic liver disease
  • Ectopic mass >3.5 cm (relative contraindication)
  • Embryonic cardiac motion (relative contraindication)
  • If <25% decline in β-hCG from day of 1st injection, 2nd dose is given
  • Worsening abdominal pain
  • Nausea, vomiting, and diarrhea
  • These are usually tubal miscarriages
  • Follow-up USs are essential to rule out ectopic rupture
  • Initial hCG >5,000 mIU (5,000-9,999 mIU/mL-13% failure rate, >15,000 mIU/mL failure rate as high as 32%)
  • Moderate to large free peritoneal fluid on US
  • Presence of fetal cardiac activity
  • Pretreatment increase in serum hCG level of more than 50% over a 48 hr period

Medication

  • Methotrexate: 50 mg/m2 IM/IV — 1
  • RhoGAM in Rh-negative women: 50 μg IM in women ≤12 wk pregnant; 300 μg IM in women >12 wk pregnant

Follow-Up

Disposition

  • Any patient with confirmed ectopic pregnancy who is hemodynamically unstable
  • Unreliable patients with increased risk factors, no available US, β-hCG >6,500 with no evidence of IUP should be admitted for observation and serial β-hCG tests
  • Decision for outpatient management should be made in conjunction with OB/GYN
  • Hemodynamically stable and reliable patients with workup that cannot rule out ectopic pregnancy:Strict follow-up for serial β-hCG tests every 2 daysPatients should be recorded in logbook with phone numbers to ensure follow-up
  • Ectopic precautions: Patients should return to emergency room immediately for:Increasing abdominal painVaginal bleedingSyncope or dizzinessPatients should not be left alone until diagnosis of ectopic pregnancy can be safely ruled outFamily and friends should also be instructed on warning signs and symptoms of ruptured/bleeding ectopic pregnancies
  • Strict follow-up for serial β-hCG tests every 2 days
  • Patients should be recorded in logbook with phone numbers to ensure follow-up
  • Increasing abdominal pain
  • Vaginal bleeding
  • Syncope or dizziness
  • Patients should not be left alone until diagnosis of ectopic pregnancy can be safely ruled out
  • Family and friends should also be instructed on warning signs and symptoms of ruptured/bleeding ectopic pregnancies

Followup Recommendations

Pearls and Pitfalls

  • Always obtain a pregnancy test on women of childbearing age
  • Obtain serum hCG and transvaginal ultrasonography in all women with positive pregnancy test presenting with abdominal pain or vaginal bleeding
  • Recognize the possibility of heterotopic pregnancies, especially in women undergoing fertility treatment
  • Secure close follow-up for any patient being evaluated and discharged for ectopic pregnancy

Additional Reading

  • Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009;361:379-387.
  • Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: The rational clinical examination systematic review. JAMA. 2013;309:1722-1729.
  • Huancahuari N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30:837-847.
  • Marx JA, Hockberger RS, Walls RM, et al. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
  • Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: A meta-analysis. Ann Emerg Med. 2010;56:674-683.

See Also (Topic, Algorithm, Electronic Media Element)

  • Pregnancy, Uncomplicated
  • Vaginal Bleeding

Codes

ICD9

  • 633.00 Abdominal pregnancy without intrauterine pregnancy
  • 633.10 Tubal pregnancy without intrauterine pregnancy
  • 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
  • 633.80 Other ectopic pregnancy without intrauterine pregnancy
  • 633.20 Ovarian pregnancy without intrauterine pregnancy

ICD10

  • O00.0 Abdominal pregnancy
  • O00.1 Tubal pregnancy
  • O00.9 Ectopic pregnancy, unspecified
  • O00.8 Other ectopic pregnancy
  • O00.2 Ovarian pregnancy
  • O00 Ectopic pregnancy

SNOMED

  • 34801009 Ectopic pregnancy (disorder)
  • 79586000 tubal pregnancy (disorder)
  • 82661006 Abdominal pregnancy
  • 17285009 Intraperitoneal pregnancy (disorder)
  • 17433009 ruptured ectopic pregnancy (disorder)
  • 9899009 ovarian pregnancy (disorder)