Ectopic Pregnancy

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Ectopic Pregnancy
Definition: Fertilized egg implants outside the uterus, most commonly in fallopian tubes (95%)
Incidence: Affects approximately 2% of all pregnancies
Significance: Potentially life-threatening condition requiring prompt diagnosis and treatment

Risk Factors
History of pelvic inflammatory disease (PID)
Previous ectopic pregnancy
Tubal surgery (including ligation or reversal)
Use of assisted reproductive technologies
Smoking
Note: Can occur in women with no identifiable risk factors

Signs and Symptoms
Abdominal pain: Sharp or stabbing, often unilateral
Vaginal bleeding: Light spotting to heavier, irregular bleeding
Amenorrhea: Missed period
Shoulder pain: Referred pain from diaphragm irritation
Dizziness or fainting: Potential indication of internal bleeding
Important: Not all symptoms may be present; presentation can mimic other conditions

Diagnosis
Medical history and physical examination: Include risk factor assessment and pelvic exam
Pregnancy test: Positive result essential for diagnosis
Transvaginal ultrasound: Visualize pregnancy location
Suspect ectopic pregnancy if: no intrauterine gestational sac and beta-hCG above 1,500 mIU/mL for transvaginal ultrasound or above 6,000 mIU/mL for transabdominal ultrasound
Serial beta-hCG levels: Critical for diagnosis and management

Serial beta-hCG Levels
Normal pregnancy: beta-hCG doubles every 1.8 to 3 days in first 6-7 weeks
Ectopic pregnancy: Slower rise, plateau, or decline in beta-hCG levels
Measurement protocol: Baseline at presentation, follow-up at 48-72 hours
Interpretation:
Normal rise (more than 66% increase): Generally indicates viable intrauterine pregnancy
Slow rise or plateau: Suggests abnormal pregnancy (ectopic or miscarriage)
Rapid decline: Usually indicates miscarriage
Slow decline: May suggest ectopic pregnancy
Caution: Overlap in beta-hCG levels between normal and ectopic pregnancies possible

Treatment
Expectant management: For small, stable ectopic pregnancies with low and declining beta-hCG levels
Methotrexate therapy: For hemodynamically stable patients with small, unruptured ectopic pregnancies with low beta-hCG levels
Surgical intervention: Necessary for large ectopics, rupture, or significant symptoms
Laparoscopic approach preferred when surgery indicated

Complications
Rupture: Surgical emergency requiring immediate intervention
Hemorrhage: Can occur even without rupture
Future fertility: Potential tubal damage affecting fertility
Emotional impact: Consider psychological support and counseling

Patient Education
Explain nature of condition and associated risks
Discuss available treatment options and their implications
Address potential long-term effects on fertility
Emphasize importance of follow-up care and monitoring
Provide resources for emotional support and counseling

Takea Home Message
Maintain high index of suspicion for ectopic pregnancy
Promptly diagnose and manage to prevent life-threatening complications
Utilize combination of clinical evaluation, ultrasound, and serial beta-hCG levels
Tailor treatment approach based on individual patient factors
Provide comprehensive patient education and support