A 24-year-old with 6 weeks' amenorrhea develops continuous lower abdominal pain and minimal vaginal bleeding. The uterus is slightly enlarged, the cervix is soft and tender on motion. There is adnexal tenderness.
The history and clinical findings are most suggestive of:
Correct Answer A:
In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity, in the fallopian tube, uterine interstitium, cervix, ovary, or abdominal or pelvic cavity. Ectopic pregnancies cannot be carried to term and eventually rupture or involute. Early symptoms and signs include pelvic pain, vaginal bleeding, and cervical motion tenderness. Syncope or hemorrhagic shock can occur with rupture.
Diagnosis is by beta-human chorionic gonadotropin measurement and ultrasonography. Treatment is with laparoscopic or open surgical resection or with IM methotrexate.
Which factor brings the most increased risk for ectopic pregnancy?
Correct Answer D:
Risk factors for ectopic pregnancy include previous ectopic pregnancy, history of a sexually transmitted disease or pelvic inflammatory disease, current use of an intrauterine device, prior pelvic (particularly tubal) surgery, and smoking. (In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation.)
Some organisms causing PID, such as Neisseria gonorrhoeae, increase the risk of ectopic pregnancy. A history of salpingitis increases the risk of ectopic pregnancy 4-fold. The incidence of tubal damage increases after successive episodes of PID (ie, 13% after 1 episode, 35% after 2 episodes, 75% after 3 episodes).
After one ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. Overall, a patient with prior ectopic pregnancy has a 50-80% chance of having a subsequent intrauterine gestation, and a 10-25% chance of a future tubal pregnancy.
In the treatment of an ectopic pregnancy with methotrexate all of the following are true, except:
Correct Answer B: Criteria for methotrexate therapy include hemodynamic stability, confirmation of ectopic pregnancy by ultrasound examination, significant risk associated with general anesthesia, patient compliance, lack of contraindications to methotrexate therapy, small size of ectopic mass (an ectopic mass is less than 3.5 cm in greatest dimension) and lack of fetal cardiac motion.
A 25-year-old primigravida presents with sharp, stabbing, left-sided pelvic pain that started yesterday, 45 days after her last menstrual period. Her past history is not remarkable, and a physical examination is normal except for moderate tenderness in the left adnexa on pelvic examination. A urinalysis is normal, as is a CBC. Her beta-hCG level is 1500 mIU/mL.
Assuming no adnexal mass is seen, which one of the following transvaginal pelvic ultrasonography findings would be consistent with the highest likelihood of an ectopic pregnancy?
At this time in the patient’s pregnancy, a gestational sac should be visible on ultrasonography. An empty uterus presents the highest risk (14%) for ectopic pregnancy, while nonspecific fluid and echogenic material are associated with a 5% and 4% risk, respectively. An abnormal or normal sac is associated with no risk, with the rare exception of multiple pregnancies with one being heterotopic.
A 21-year-old married Hispanic female who is using no method of contraception presents to your office for evaluation of vaginal spotting 6 weeks after her last menstrual period. Her periods have previously been regular. She has had one previous episode of pelvic inflammatory disease. A home pregnancy test is positive.
Which one of the following is true in this situation?
Correct Answer A: Early diagnosis of ectopic pregnancy requires a high index of suspicion. Risk factors include previous ectopic pregnancy, tubal sterilization, pelvic inflammatory disease, IUD use, and in utero exposure to diethylstilbestrol. The classic triad of missed menses, pain, and bleeding may not also be present. In early pregnancies of less than 5 weeks gestation, serial hCG levels are helpful. Serum hCG levels double every 1.4 - 2 days. In a healthy pregnancy the level is expected to increase by at least 66% in 48 hours. Combining serial hCG levels with transvaginal ultrasonography is the best combination for evaluation of first-trimester problems.
Serum hCG levels correlate well with sonographic landmarks. At 5 weeks gestation in a normal pregnancy, serum hCG is > 1000 mIU/mL and a gestational sac can be visualized in the uterus. Serum hCG is > 2500 mIU/mL at 6 weeks and a yolk sac can be seen within the gestational sac. An hCG level of 5000 mIU/mL is compatible with visualization of a fetal pole. When the level is 17,000 mIU/mL, cardiac activity is detectable.
Progesterone levels are also predictive of fetal outcome. A single level of 25 ng/mL or higher indicates a healthy pregnancy and excludes ectopic pregnancy with a sensitivity of 98%. If the level is < 5 ng/mL, the pregnancy is nonviable. Assessment of fetal well-being is difficult if levels are in the intermediate range of 5 - 25 ng/mL.
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