Ectopic Pregnancy (core) | ~ 1 in 50 pregnancies is ectopic Typical presentation: first-trimester abdominal/pelvic pain and/or vaginal bleeding Ask about last menstrual period, contraception Can cause life-threatening hemorrhage Risk factors: history of PID, fertility treatment, prior ectopic pregnancies or tubal surgery, increasing age, current IUD (unlikely to get pregnant; however, if pregnancy occurs, 53% chance of ectopic) | CBC, type and screen Serum hCG - If patient has pregnancy of unknown location and is stable, repeat hCG q48-72h to assess if hCG is rising appropriately - In normal early pregnancy, hCG should double in 48-72 h (varies by gestational age) - Slow increase in hCG may indicate an ectopic pregnancy Transvaginal U/S—useful for identifying intrauterine pregnancy vs determining location of an ectopic pregnancy, may demonstrate fluid in pelvis FAST—can be used in unstable patient with suspected ruptured ectopic to assess for intra-abdominal hemorrhage | Initiate resuscitation if patient is in hemorrhagic shock Methotrexate (MTX) is the medical treatment option for ectopic pregnancy - Can be used in stable patients with unruptured ectopic pregnancy - Patient must be reliable and able to return to care to trend hCG after treatment and in case of treatment failure or rupture - Relative contraindications: hCG > 5000, ectopic > 4 cm, fetal cardiac activity Surgical intervention required for some patients - Hemodynamically unstable patients, ruptured ectopic, patients with contraindication to MTX, advanced gestation (hCG > 5000, fetal cardiac activity, ectopic > 4 cm), or if patient elects surgical management - Salpingostomy vs salpingectomy If fallopian tube is not ruptured, can do tubal salpingostomy If fallopian tube damaged/ruptured or there is persistent tubal bleeding, then salpingectomy preferred - Rh(-) woman should receive anti-D immunoglobulin (Rhogam) within 72 h to prevent alloimmunization | Laparoscopic salpingostomy: - Lift the fallopian tube with atraumatic grasper - Inject vasopressin solution along the mesosalpinx beneath the ectopic pregnancy - Make a 1-2 cm longitudinal incision with monopolar cautery along the site of ectopic - Use hydrodissection or gentle blunt dissection to remove the ectopic - Obtain hemostasis, leave tubal incision open Laparoscopic salpingectomy: |