Ectopic pregnancy

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Definitions

Ectopic pregnancy is defined as any pregnancy that occurs outside the uterine cavity. Approximately 97% of ectopic pregnancies occur in the fallopian tube, with 55% of these occurring in the ampulla, 25% in the isthmus, and 17% located in the fimbria. The remaining 3% of ectopic pregnancies are located in ovarian, cervical, abdominal, and intersitial (cornual) sites [1]. A heterotopic pregnancy is a coexistent intrauterine and ectopic pregnancy. The rate of heterotopic pregnancy varies from 1

Clinical findings

The classic triad for the patient who presents with an ectopic pregnancy is amenorrhea, abdominal pain, and vaginal bleeding. Unfortunately, these findings are nonspecific and actually occur more commonly in the patient who has a threatened miscarriage than in an ectopic pregnancy [1]. Questioning the patient regarding previous ectopic pregnancy, history of pelvic inflammatory disease, use of an intrauterine device (IUD), and tubal surgery can increase one's level of suspicion when evaluating a

Laboratory findings

The emergency physician uses beta-human chorionic gonadotropin (β-hCG) to diagnose the pregnancy and to assist in determining the potential of the patient having an ectopic pregnancy. Beta-human chorionic gonadotropin is produced by the trophoblasts and may be detectable in the serum as early as 1 week before expected menses. Most laboratories test for serum levels as low as 5 mIU/mL and urine levels in the 20 mIU/mL to 50 mIU/mL range. False-negative results can occur with the urine testing,

Ultrasound testing

Over the decade, physicians in the emergency department have increasingly used ultrasonography in the evaluation of first trimester complications of pregnancy. Several studies have validated the ability of emergency physicians to complete pelvic ultrasound evaluations with minimal training [18], [19], [20], [21]. One major impact of ultrasonography performed by the emergency physician is that the length of stay in the emergency department has been shown to decrease by as much as 120 minutes [22]

Findings diagnostic of IUP

The primary objective for the emergency physician is to attempt to demonstrate an IUP. The demonstration of an IUP effectively rules out ectopic pregnancy because the risk of heterotopic pregnancy is relatively uncommon. Caution must still be used in the patient who is undergoing reproductive assistance, because of the higher risk of heterotopic pregnancy. Diagnosing an IUP in a patient with abdominal pain, vaginal bleeding, or both allows the emergency physician to focus on alternate diagnoses

Findings diagnostic or suggestive of ectopic pregnancy

The only true ultrasonic finding diagnostic of an ectopic pregnancy is visualization of a gestational sac with yolk sac or fetal pole outside the endometrial cavity. Numerous other findings are highly suggestive but not diagnostic of ectopic pregnancy. These findings include a β-hCG level above the discriminatory zone with an empty uterus, an adnexal mass that is anything other than a simple cyst and is separate from the ovary, any echogenic fluid in the cul-de-sac, and a moderate to large

Clinical approach

The approach to ectopic pregnancy (Fig. 1) begins with developing a clinical suspicion for the entity. History and physical examination characteristics are poor predictors [1], [43]. Any woman of reproductive age who presents to the emergency department with vaginal bleeding, abdominal pain, syncope, hypotension, or altered mental status should have a pregnancy test.

If the patient is pregnant, then hemodynamic instability, a low hematocrit, or an acute abdomen warrants immediate obstetric

Summary

Ectopic pregnancy is a high-risk diagnosis that is increasing in frequency and is still commonly missed in the emergency department. The emergency physician needs a high index of suspicion and must understand that the history, physical examination, and a single quantitative β-hCG level cannot reliably rule out an ectopic pregnancy. Most pregnant patients who present to the emergency department during the first trimester with abdominal or pelvic pain, regardless of the presence of vaginal

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    The opinions and assertions contained herein are the private views of the authors and should not be construed as official or as reflecting the views of the Department of Army or the Department of Defense.

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