Ectopic pregnancy: Clinical sciences

2,295views

00:00 / 00:00

Decision-Making Tree

Questions

USMLE® Step 2 style questions USMLE

0 of 4 complete

A 36-year-old woman, gravida 4, para 2, aborta 1, at 6 weeks gestational age by last menstrual period, presents to the emergency department with left lower quadrant pain and vaginal bleeding. She and her partner have been trying to conceive and had a positive home pregnancy test last week. Her initial antenatal appointment is scheduled for next week. Past medical history is notable for two uncomplicated spontaneous vaginal deliveries and one ruptured ectopic pregnancy treated with a right salpingectomy 6 years ago. She also has a history of endometriosis and mild intermittent asthma requiring the use of albuterol 2 to 3 times per month. Temperature is 37.1 °C (98.7 °F), heart rate is 86 bpm, respirations are 18/min, and blood pressure is 128/76 mmHg. Weight is 125 pounds. The exam is notable for left adnexal tenderness and a small amount of bright red blood in the vaginal vault. Labs are obtained, with results shown below. A transvaginal ultrasound shows an empty uterine cavity and a 3.2 cm complex left adnexal mass. Neither a gestational sac, yolk sac, nor embryo are visible. Which of the following clinical factors indicates the need for surgical management in this patient? 
 
 Lab values      Results   
 Hemoglobin      12.1  g/dL    
 Total leukocyte count     7500/mm³    
 Platelet count     87,000/mm³    
 Blood urea nitrogen (BUN)     23 mg/dL    
 Creatinine     1.3  mg/dL    
 Aspartate aminotransferase      20 U/L    
 Human Chorionic gonadotropin     4200 mIU/ml    

Transcript

Watch video only

An ectopic pregnancy is a pregnancy that develops outside of the uterine cavity. Now, in an intrauterine pregnancy, embryonic tissue implants within the decidualized endometrium at or near the top of the uterus. However, in ectopic pregnancy, the embryonic tissue typically implants in the fallopian tube, most commonly in the ampulla, but it can also occur in the isthmus or interstitial areas of the tube. Other sites of abnormal implantation include the abdomen, cervix, or c-section scar. Rarely, an ectopic pregnancy can be present along with an intrauterine pregnancy, which is called a heterotopic pregnancy.

Your first step in evaluating a patient presenting with a chief concern suggesting an ectopic pregnancy is to assess their CABCDE to determine if they are unstable. An ectopic pregnancy can rupture at any time leading to extensive intraperitoneal hemorrhage. Because of this, start your management with type and cross for possible packed red blood cell transfusion. Then, stabilize their airway, breathing, and circulation. Also, consider intubation as clinically indicated, obtain IV access, and continuously monitor vital signs.

Next, obtain a focused history and physical exam, and check labs, including CBC, CMP, and hCG, or human chorionic gonadotropin. Additionally, perform an ultrasound to assess pregnancy location and evaluate for the presence of free fluid in the abdomen or cul-de-sac of the pelvis.

Alright, the patient might report delayed or missed menses, syncope, abdominal or pelvic pain, and vaginal bleeding. On physical exam, you’ll find signs of hemodynamic instability like hypotension and tachycardia, altered mental status, and pale and clammy skin. Next, you’ll usually see signs of acute abdomen like abdominal tenderness, guarding, and rebound pain indicating intraperitoneal bleeding is present. Lastly, on pelvic exam, you may observe bleeding from the cervical os. As for the labs, they usually reveal a positive hCG and probably anemia. Finally the ultrasound will show an empty uterus without signs of an intrauterine pregnancy, possible free fluid in the abdomen or posterior cul-de-sac of the pelvis, and sometimes an adnexal mass.

Sources

  1. "ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy" Obstet Gynecol (2018)