A 26-year-old lady with gravida 3, para 1 arrives at the Emergency department with spotting. Her last menstrual period occurred at an unknown time. Her medical history is remarkable for an ectopic pregnancy two years ago, which was treated with a laparoscopic salpingectomy.
- Blood pressure : 110/62
- Pulse 73 beats per minute
- Respiratory rate: 16
- Abdomen soft and nontender
- Uterus enlarged , nontender with palpable right adnexal mass
- Serum B-HCG 1600 mIU/Ml
- Hematocrit 36%
- 8 mm endometrial thickness with no inrauterine gestational sac
- Ovaries normal
- 3 cm complex mass in the right ovary identrififed.
- No other adnexal masses
- No fluid in the pouch of Douglas
- History of ectopic pregnancy
- Clinically stable
- hCG level of 1600 mIU/m
- Endometrial thickness and no intrauterine gestational sac
- Methotrexate sodium
- Dilation and curettage
- Diagnostic laparoscopy
- Serum progesterone level
- HCG level measurement in 48 hours
HCG level measurement in 48 hours
An ectopic pregnancy is defined as any pregnancy that implants outside of the uterine cavity. In the United Kingdom, the incidence is around 11/1000 pregnancies, with an estimated 11 000 ectopic pregnancies diagnosed each year.
The presence of a yolk sac or a fetus outside of the typical intrauterine site, with or without cardiac activity, is required for a definite diagnosis of an ectopic pregnancy.
The discriminating zone is commonly defined as an hCG level of 1,500–2,000 mIU/mL, which is related with the appearance of a normal singleton pregnancy on transvaginal ultrasonography. A viable intrauterine pregnancy is discovered in approximately 4.5% of pregnant women with an initial hCG level greater than 2,000 mIU/mL and no visible intrauterine fluid collection.
Offer Expectant management for women who are clinically stable and pain free, have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan, have serum hCG levels of 1,000 IU/L or less and are able to return for follow-up.
Offer Methotrexate for women who have no significant pain, have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat, have a serum hCG level less than 1,500 IU/litre, do not have an intrauterine pregnancy (as confirmed on an ultrasound scan), and are able to return for follow-up.
Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment, or who have any of the following: an ectopic pregnancy and significant pain, an ectopic pregnancy with an adnexal mass of 35 mm or larger, an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan, an ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more. (Check out QuizMe 7)
- National Institute for Health and Care Excellence. (2019). Ectopic pregnancy and miscarriage: diagnosis and initial management (NICE guideline Published: 17 April 2019). Retrieved from https://www.nice.org.uk/guidance/ng126/resources/ectopic-pregnancy-and-miscarriage-diagnosis-and-initial-management-pdf-66141662244037
- Royal College of Obstetricians and Gynaecologists. (2016). Diagnosis and Management of EctopicPregnancy (Green-top Guideline No. 21). Retrieved from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/
- Rueangket, P., & Rittiluechai, K. (2021). Predictive Analytic Model for Diagnosis of Ectopic Pregnancy. Frontiers in medicine, 8, 646258. https://doi.org/10.3389/fmed.2021.646258