Complicated pregnancy

Ectopic pregnancy

• Fertilized egg attaches outside of uterus (MC ampulla of fallopian tubes)

• Risk factors: HX of ectopics (highest RF), PID, smoking

• SSX ~4-6wks after LMP

  • Interstitial pregnancy (rare) presents ~8-12wks after LMP

  • ABD pain, guarding, nausea

  • Tenderness at site, ± CMT

  • Amenorrhea OR vaginal bleeding

• SSX of rupture

  • Acute ABD with ssx of shock

  • Blood in peritoneal cavity ➔ diaphragmatic irritation ➔ shoulder pain

• DX

  • Transvaginal US is best test, bedside US is first test if rupture suspected

  • HCG and call an adult (OB/GYN) and get US even if HCG negative

  • HCG discriminatory level: Intrauterine pregnancy typically seen on US when HCG > 1,500-2,000

    • If IUP not seen and HCG > discriminatory level ➔ likely ectopic

    • Serial HCG: After 48hrs HCG should raise in IUP

      • Ectopic or spontaneous abortion may ➔ falling HCG

  • If unstable - GET AN ADULT for exploratory laparoscopy and don't wait for imaging

    • Laparotomy if critically unstable

• TX

  • Hemodynamically stable

    • AND HCG < 5,000

    • AND able to return for f/u HCG

    • Methotrexate (CI in renal insufficiency, avoid in PUD, immunodeficient, pulmonary disease)

      • ↓ effectiveness of MTX if HCG >5k, fetal cardiac activity is present, ectopic > 3.5cm

    • Expectant management only for small population (asx, HCG <200 and declining, no findings on US)

  • Hemodynamically unstable

  • OR SSX of rupture

  • OR HCG > 5,000/8wks since LMP

    • Surgery - salpingectomy (does not preserve function)