Ectopic Pregnancy, Ruptured

• • Severe abdominal tenderness with guarding

  • Hemodynamic instability

  • Adnexal mass

Epidemiology

• • 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

Symptoms and Signs

• • Sudden-onset lower abdominal pain with guarding

  • Lower back discomfort

  • Hemodynamic instability

  • Adnexal mass

  • Amenorrhea

  • Current or recent history of vaginal spotting/bleeding

Laboratory Findings

• • Positive β-hCG

  • Lowered Hgb

  • Slight leukocytosis

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

  • Progesterone level < 5 ng/mL

Imaging Findings

• • 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

• • 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

Rule Out

• • Threatened abortion

  • Missed abortion

• • CBC

  • Basic chemistries

  • β-hCG

  • Serum progesterone

  • Prothrombin time and partial thromboplastin time

  • Transvaginal US

When to Admit

• • 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

When to Refer

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

• • 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

Surgery

Indications

• • All patients with ruptured ectopic pregnancy require immediate laparotomy

  • Laparoscopic approaches to nonruptured ectopic pregnancies are gaining popularity

Medications

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

Treatment Monitoring

• • β-hCG levels should return to normal values

  • Hgb stabilization

Complications

• • Infertility

  • Repeat ectopic pregnancy

Prognosis

• • 0.3% ...