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  • • Severe abdominal tenderness with guarding

    • Hemodynamic instability

    • Adnexal mass

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Epidemiology

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  • • Incidence has increased with the use of advanced reproductive technologies

    • At least 2 in every 100 pregnancies are ectopic

    • Mortality 0.3% in ectopic pregnancy

    • 95% of ectopic pregnancies occur in the uterine tube, usually in the ampullary portion

    • In vitro fertilization has increased the incidence of heterotopic pregnancy (intrauterine + ectopic)

    • Risk factors include:

    • -Prior ectopic pregnancy

      -History of pelvic inflammatory disease (PID)

      -Prior pelvic surgery

      -In vitro fertilization

      -Current intrauterine device use

      -Smoking

      -Diethylstilbestrol exposure

      -Increasing age

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Symptoms and Signs

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  • • Sudden-onset lower abdominal pain with guarding

    • Lower back discomfort

    • Hemodynamic instability

    • Adnexal mass

    • Amenorrhea

    • Current or recent history of vaginal spotting/bleeding

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Laboratory Findings

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  • • Positive β-hCG

    • Lowered Hgb

    • Slight leukocytosis

    • Lower values of quantitative β-hCG for gestational age of fetus

    • Progesterone level < 5 ng/mL

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Imaging Findings

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  • • Transvaginal US is the radiographic procedure of choice

    • -Free fluid in the cul-de-sac

      -Absence of intrauterine gestational sac—especially when β-hCG level is > 2000 mIU/mL (a threshold value above which an intrauterine gestational sac should be detected)

      -Presence of adnexal mass

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  • • Threatened spontaneous abortion

    • Missed abortion

    • Acute appendicitis

    • Acute PID

    • Ruptured corpus luteum cyst

    • Ureteral colic

    • Hemorrhagic ovarian cysts or tumors

    • Torsed ovarian cysts or tumor

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Rule Out

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  • • Threatened abortion

    • Missed abortion

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  • • CBC

    • Basic chemistries

    • β-hCG

    • Serum progesterone

    • Prothrombin time and partial thromboplastin time

    • Transvaginal US

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When to Admit

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  • • Many uncomplicated ectopic pregnancies are diagnosed and managed in clinician's offices as an outpatient

    • All patients with a ruptured ectopic pregnancy should be admitted for urgent surgical exploration

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When to Refer

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  • • All patients with suspected ectopic pregnancy should be managed by a gynecology-trained surgeon

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  • • Treatment is surgical

    • Goals are to control hemorrhage and preserve as much uterine tube as possible

    • Serial Hgb evaluation

    • Cross-matched blood on reserve

    • Determine Rh status

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Surgery

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Indications

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  • • All patients with ruptured ectopic pregnancy require immediate laparotomy

    • Laparoscopic approaches to nonruptured ectopic pregnancies are gaining popularity

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Medications

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  • • RH0(D) immune globulin to patients who are Rh negative

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Treatment Monitoring

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  • • β-hCG levels should return to normal values

    • Hgb stabilization

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Complications

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  • • Infertility

    • Repeat ectopic pregnancy

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Prognosis

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  • • 0.3% mortality

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References

Lehner R et al. Ectopic pregnancy. Arch ...

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