Clinical Approach

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The possibility of ectopic pregnancy must be considered when assessing a pregnant woman with vaginal spotting and/or lower abdominal pain. It is of paramount importance to determine if the woman is hypotensive, volume depleted, or has severe abdominal or adnexal pain. These patients most likely will require laparoscopy or laparotomy because ectopic pregnancy is probable. For asymptomatic women, the quantitative hCG level is useful. When the hCG level is below the threshold for sonographic visualization of an intrauterine gestational sac, then a repeat hCG level is generally performed in 48 hr to establish the viability of the pregnancy. Another option would be a single progesterone level: levels greater than 25 ng/mL almost always indicate a normal intrauterine gestation, whereas values less than 5 ng/mL usually correlate with a nonviable gestation. When a nonviable pregnancy is diagnosed either by an abnormal hCG rise or a single progesterone assay (<5 ng/mL), then whether the patient has a spontaneous abortion or an ectopic pregnancy still is unclear. Many clinicians will perform a uterine curettage at this time to assess whether the patient has a miscarriage (histologic confirmation of chorionic villi) or an ectopic pregnancy (no villi from the curettage). Women with asymptomatic, small (<3.5 cm) ectopic pregnancies are ideal candidates for intramuscular methotrexate.

A nonviable intrauterine pregnancy can be managed expectantly, surgically via dilation and curettage or medically with vaginal misoprostol. Vaginal misoprostol has been reported to be effective in evacuating the pregnancy in approximately 80% of cases.

When the hCG level is greater than the ultrasound threshold, then a transvaginal sonogram will dictate the next step. A patient in whom an intrauterine gestational sac is seen may be sent home with a diagnosis of threatened abortion and should undergo close follow-up. The risk of miscarriage still is significant. When the hCG level Is above the threshold and no evidence of intrauterine pregnancy is seen on sonography, the risk of ectopic pregnancy is high (approximately 85%). and laparoscopy often is undertaken to diagnose and treat the ectopic pregnancy. Because an intrauterine gestation is possible in this circumstance (approximately 15% of the time), methotrexate usually is not given: however, a high hCG level in the face of a sonographi-cally empty uterus almost always is caused by an extrauterine gestation (one example of a management scheme is shown in Figure 7-1). Finally, Rh-negative

Rhogam Algorithm
Figure 7-1. Algorithm for management of suspected ectopic pregnancy.

women with threatened abortion, spontaneous abortion, or ectopic pregnancy should receive RhoGAM to prevent isoimmunization.

Comprehension Questions

[7.1] Which of the following is a risk factor for the development of an ectopic pregnancy?

A. Prior chlamydial cervical infection

B. History of a tubal ligation

C. Prior molar pregnancy

D. Prior miscarriage

E. Combination oral contraceptive pill use

[7.2] A 32-year-old woman is diagnosed with an ectopic pregnancy based on hCG levels that plateaued in the range of 14(X) mlU/mL and no chorionic villi found on uterine curettage. She is given 50 mg/m: methotrexate intramuscularly. Five days later, she complains of increased lower abdominal pain. Her blood pressure and heart rate are normal. Her abdomen shows some tenderness in the lower quadrants without guarding or rebound. Which of the following is the best course of action?

A. Immediate laparotomy

B. Repeat dose of methotrexate

C. Observation

D. Folic acid rescue

E. Epidural analgesia

[7.3] An 18-year-old woman who is brought to the emergency room complains of vaginal spotting and lower abdominal pain. Her abdominal and pelvic examinations are normal. The hCG level is 700 mlU/mL, and transvaginal sonogram shows no intrauterine gestational sac and no adnexal masses. Which of the following statements is most accurate regarding this patient's situation?

A. She has an unruptured ectopic pregnancy.

B. She has a viable intrauterine pregnancy that is too early to assess by ultrasound.

C. She has a nonviable intrauterine pregnancy.

D. There is insufficient information to draw a conclusion about the viability of this pregnancy.

E. Magnetic resonance imaging scan would be useful in further assessing the possibility of an ectopic pregnancy.

[7.4] A 22-year-old woman who is pregnant at 5 weeks' gestation complains of severe lower abdominal pain. On examination, her blood pressure is 86/44 and heart rate 120 bpm. Her abdomen is tender. Pelvic examination is difficult to perform due to guarding. The hCG level is 500 mIU/mL, and the transvaginal sonogram reveals no intrauterine gestational sac and no adnexal masses. Some free fluid is present in the cul-de-sac. Which of the following is the best management for this patient?

A. Repeat hCG level in 48 hr to assess for a rise of 66%

B. Check the serum progesterone level

C. Immediate surgery

D. Intramuscular methotrexate

E. Repeat sonography in 48 hr

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