Ectopic Pregnancy Ch 25 2009 2010 Academic Year

Case Presentation A 37 o G 5 P 3013 with LMP 8 weeks ago

Differential Diagnosis w GYN w NON-GYN w SAB w Ruptured corpeus luteum cyst w

Risk Factors for Ectopic w Hx of tubal surgery w Hx of STD’s (such

Adapted from Hacker, et al. 4 th ed. Figure 25 -1 Possible locations of

Incidence and Location w 1 in 80 spontaneous pregnancies w Tubal w 80% Ampullary

Locations of Etopics Adapted from www. ectopicpregnancyfoundation. org 2009 -2010 USUHS MSIII Ob/Gyn Clerkship

Diagnosis w If HCG is above discriminatory value (15002000 depending on hospital), then US

Adapted from Hacker, et al. 4 th ed. Distribution curve of h. CG in

Adapted from Hacker, et al. 4 th ed. Algorithm for diagnosis and treatment of

Treatment Options w Medical Management w Methotrexate (See Table 25 -1, pg 333) w

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Ectopic Pregnancy Ch 25 2009 -2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study

Case Presentation A 37 o G 5 P 3013 with LMP 8 weeks ago presents to the ED with RLQ pain, nausea and vomiting, and vaginal spotting. The ED provider was concerned that the patient may have appendicitis because of her history, as well as her past surgical history significant for a tubal ligation. Initial lab work revealed a positive h. CG. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Differential Diagnosis w GYN w NON-GYN w SAB w Ruptured corpeus luteum cyst w PID w Adnexal torsion w Degenerating fibroid 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies w w Appendicitis Pyelonephritis Pancreatitis Peritonitis from other cause

Risk Factors for Ectopic w Hx of tubal surgery w Hx of STD’s (such as chlamydia) w Hx of ART (assisted reproductive technology - IVF, clomid, etc) w Hx of ectopic (esp if conservatively managed without surgery) w Smoking w IUD in place at time of conception 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Adapted from Hacker, et al. 4 th ed. Figure 25 -1 Possible locations of ectopic pregnancy with spontaneous conception versus pregnancies that result from assisted reproductive technologies (ART) such as in vitro fertilization (IVF). Modified from Pisarska MD et al: Clin Obstet Gynecol 42: 3, 1999. Downloaded from: Student. Consult (on 16 June 2009 03: 48 AM) 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies © 2005 Elsevier

Incidence and Location w 1 in 80 spontaneous pregnancies w Tubal w 80% Ampullary w 12% Isthmic w 6% Fimbrial w 2% Interstitial w Cervical, intraperitoneal, ovarian 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Locations of Etopics Adapted from www. ectopicpregnancyfoundation. org 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Diagnosis w If HCG is above discriminatory value (15002000 depending on hospital), then US w US evaluation (Intra-uterine vs. extra) w HCQ - 66% of pregnancies double in 48 h w Clinical Sx’s (bleeding, pain, hx of amenorrhea) 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Adapted from Hacker, et al. 4 th ed. Distribution curve of h. CG in normal pregnancies with an ex of a Discriminatory zone (DZ) in the shaded area. J Obstet Gynecol 152: 299, 1985. Downloaded from: Student. Consult (on 16 June 2009 03: 48 AM) 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies © 2005 Elsevier

Adapted from Hacker, et al. 4 th ed. Algorithm for diagnosis and treatment of ectopic in non-acute, stable patient. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies Downloaded from: Student. Consult (on 16 June 2009 03: 48 AM) © 2005 Elsevier

Treatment Options w Medical Management w Methotrexate (See Table 25 -1, pg 333) w Surgical Management w Salpingostomy (incision in tube) w Salpingectomy (removal of tube) w Open abdominal incision or laparoscopy (depending on stability of patient) 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies