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Potentially life-threatening emergency
Ectopic pregnancy
Other Resources UpToDate PubMed
Potentially life-threatening emergency

Ectopic pregnancy

Contributors: Mitchell Linder MD, Paritosh Prasad MD
Other Resources UpToDate PubMed

Synopsis

The term ectopic pregnancy refers to implantation of a developing blastocyst at any location outside of the endometrial cavity. Ectopic pregnancies can be found in the cervix, cornua, fallopian tubes, ovaries, or a prior cesarean section (C-section) scar, or, more rarely, attached to the abdominal lining, bowel, or other viscera. The most common location is the fallopian tube, specifically the ampulla, which accounts for about 70%-80% of cases, followed by the isthmus and fimbria. Prevalence is estimated at 25 in 1000 pregnancies, with less than 200 000 cases in the United States per year. It is a medical emergency.

Ectopic pregnancies are by definition nonviable. If left untreated, they may cause their containing structure (eg, fallopian tube, cornua, scar) to rupture, leading to acute blood loss and subsequent morbidity and possibly death. Improved technology (biochemical markers, ultrasonography, etc) has enabled healthcare practitioners to identify a majority of ectopic pregnancies before rupture to reduce associated morbidity and mortality.

Ectopic pregnancies are found in reproductive-age women. Risk factors include prior ectopic pregnancy, history of endometriosis or tubal infection (pelvic inflammatory disease), use of progesterone intrauterine device (IUD), history of tubal surgery, advanced maternal age (eg, third or fourth decade), and tobacco use.

Presentation can vary. Patients may present with a positive home pregnancy test and unilateral lower quadrant pain that is often sharp / stabbing in nature. Some will present after tubal rupture and be hemodynamically unstable. Others may present with only vaginal spotting and be unaware they are even pregnant. Therefore, one must have a high index of suspicion when a patient arrives with a positive pregnancy test and symptomatology. As many as 16% of women presenting to the emergency department with first-trimester bleeding, pain, or both will be found to have an ectopic pregnancy.

Ruptured ectopic pregnancy can result in intraperitoneal bleeding, uterine hemorrhage, and hemodynamic instability. Development of any of these complications should be considered a surgical emergency and warrants emergent evaluation by a gynecologic surgeon; exploratory laparotomy may be required. Even in the absence of concern for rupture, surgery may be considered, particularly in patients failing or with contraindications to methotrexate, in the setting of heterotopic pregnancy (ectopic pregnancy occurring simultaneously with a viable intrauterine pregnancy; see Look For), or in patients seeking sterilization.

A 2011 consensus statement provides definitions that draw attention to the complexity of evaluating for and diagnosing ectopic pregnancy, with 5 categories based on sonographic findings:
  1. Definitive intrauterine pregnancy
  2. Probable intrauterine pregnancy
  3. Pregnancy of unknown location
  4. Probable ectopic pregnancy
  5. Definite ectopic pregnancy
A "pregnancy of unknown location" (PUL) should be considered when a transvaginal ultrasound demonstrates neither an intrauterine pregnancy (IUP) nor a definitive extrauterine pregnancy despite a positive serum human chorionic gonadotropin (hCG) titer. With an hCG titer of 1500 IU/L or greater, the gestational sac should be visualizable by transvaginal ultrasound, and absence of an IUP generally indicates a tubal ectopic, although nontubal ectopic, abnormal IUP, or earlier-than-expected IUP should also be considered.

Codes

ICD10CM:
O00.90 – Unspecified ectopic pregnancy without intrauterine pregnancy

SNOMEDCT:
34801009 – Ectopic pregnancy

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Last Reviewed:12/18/2019
Last Updated:01/06/2020
Copyright © 2021 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Ectopic pregnancy
Ectopic pregnancy : Abdominal pain, Dizziness, Elevated urine hCG level, Pelvic pain, Vaginal bleeding, Adnexal mass on pelvic exam, Menstrual period late
Imaging Studies image of Ectopic pregnancy
Axial CT image demonstrates high attenuation fluid in the pelvis consistent with blood. Patient with subsequent positive pregnancy test, and found to have ruptured ectopic pregnancy.
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