QuizMe 7

Vaginal Bleeding

A 23 year old female patient presented to A&E with a 3 day history of vaginal bleeding and lower abdominal cramping. She is sexually active and reported that her last menstrual period was 8 weeks ago. A genital exam was performed revealing a closed cervix and moderate vaginal bleeding. A pregnancy test was positive. Serum β-hCG level of 10,000 mIU/mL on presentation.

  • Vaginal bleeding
  • Late period
  • Lower abdominal pain
  • Positive pregnancy test
  • Miscarriage
  • Ectopic pregnancy

Transvaginal Ultrasound

Empty uterus, right-adnexal mass that is 4.5 cm, no fetal cardiac activity,small amount of free fluid in the pelvis

  • Reassure and repeat serum β-hCG level in 2 days
  • Intramuscular injection of methotrexate
  • Surgical treatment
  • Methotrexate injection into adnexal mass

Surgical management

Ectopic pregnancies make up around 1–2% of all pregnancies and account for 4-10% pregnancy related-deaths. Absence of an intrauterine gestational sac in the presence of a β-hCG value of 2,000 IU/L may flag an ectopic pregnancy.

Methotrexate (MTX), an antimetabolite, can be considered for women with a confirmed, or high clinical suspicion of ectopic pregnancy who are hemodynamically stable with an unruptured mass. Success rates of 81-98% have been reported if serum β-hCG value are less than 1 ,000 IU/L compared to only 38% if β-hCG are greater than 5,000 IU/L

Leaving surgery as the preferred modality of management in this patient. Laparoscopic surgical approach is preferred over the open approach. Salpingectomy is advised, if the contralateral tube is healthy. Salpingotomy is recommended in women with a history of fertility-reducing factors (e.g. Previous ectopic pregnancy, damaged contralateral tube, etc…),Follow up is needed to make sure β-hCG values return to non-pregnant levels.

IMPORTANT: Anti-D prophylaxis should be given as per national protocol to all RhD-negative women

  • Marion, L. L., & Meeks, G. R. (2012). Ectopic pregnancy: History, incidence, epidemiology, and risk factors. Clinical Obstetrics and Gynecology, 55(2), 376–386. https://doi.org/10.1097/GRF.0b013e3182516d7b
  • Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk EJ on behalf of the Royal College ofObstetricians and Gynaecologists. Diagnosis and management of ectopic pregnancy. BJOG 2016;.123:e15–e55
  • Marret, H., Fauconnier, A., Dubernard, G., Misme, H., Lagarce, L., Lesavre, M., Fernandez, H., Mimoun, C., Tourette, C., Curinier, S., Rabishong, B., & Agostini, A. (2016). Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: report by CNGOF. In European Journal of Obstetrics and Gynecology and Reproductive Biology (Vol. 205, pp. 105–109). Elsevier Ireland Ltd. https://doi.org/10.1016/j.ejogrb.2016.07.489
Author

Dr Aya Al-Shati & Dr Mustafa Qasem

Reviewer

Mr Moiad Alazzam