Evaluation of Abnormal Pregnancies Ectopic Pregnancy Hedwige Saint-Louis July 10, 2005 37 yo G3 P2 with LMP 5 wks ago presents

s with 2-3 day history of abdominal pain. She describes the pain as starting around the umbilicus then migrating to the right lower quadrant over the first two days then finally getting more generalized. On presentation, the patient is stable with a B/P of 135/89, P 90. Her abdominal exam is benign and her pelvic exam is only significant for very mild right adnexal tenderness. Her UCG is positive, quantitative hCG is 534 and PCV is 30 . On pelvic US a small amount of fluid is seen in the posterior cul-de-sac but no adnexal masses are seen and nothing is seen in the uterus. What is your differential diagnosis? Ectopic pregnancy is high on the list followed by early IUP with ruptured corpus luteum cyst. Less likely include early pregnancy with other nonpregnancy-related causes of pain such as appendicitis, UTI, gastroenteritis, or GU stone. What is the incidence of ectopic pregnancies in the general population? The incidence is about 1 in 200 pregnancies. This rate has been increasing in the past few years due to the increase incidence of PID. Other factors associated with ectopic pregnancies include prior ectopic pregnancy, cigarette smoking, prior tubal surgery, diethylstilbestrol exposure and increasing age. In population with high incidence of PID, the rate of ectopic pregnancies is 1 in 40 pregnancies. In women with a prior BTL, up to 36.5 per 1000 procedures done will result in a failure depending on the BTL method, of those, approximately 1/3 will be ectopic pregnancies. If she had a prior ectopic pregnancy or a history of PID, she has a 15% risk of an ectopic with the subsequent pregnancy. What is the most common presentation of patients with an ectopic pregnancy? Classical symptoms of an ectopic pregnancy include: irregular bleeding, late menses, abdominal pain and symptoms of pregnancy (i.e. breast tenderness, nausea.) On physical examination the patient may have any of the following: abdominal pain with peritoneal signs, adnexal tenderness or fullness, but any of the components of this presentation may be missing. When do symptoms occur? Pain symptoms usually occur during the second to third month of pregnancy when the pregnancy causes distention and possible rupture of the tube. In a cornual ectopic pregnancy, pain often may not present until the 3rd or 4th month of pregnancy since the corneal area has myometrium, allowing for more advanced pregnancy development before sudden and catastrophic rupture of the uterine cornual and tube. However symptoms may present very early in the pregnancy. What diagnostic instruments should be used when the clinical presentation is inconclusive? Clinical diagnosis is 75% accurate, at best. Using serum hCG levels and ultrasound can increase the accuracy of your diagnosis. A serum hCG that does not double over a period of 48 hrs suggests that the patient may have an abnormal pregnancy: ectopic pregnancy or abnormal IUP. It is important to note that serial hCG levels should be compared only when performed in the same lab. Less than 10% of normal pregnancy will have an abnormal rise in the serum hCG and over 90% of ectopic pregnancies will be accompanied of an abnormal rise in the serum hCG. Transvaginal ultrasound demonstrating an empty uterus at serum hCG levels of at least 1500 mIU/mL (depending on the type of hCG assay) is also indicative of an ectopic pregnancy. A cornual

pregnancy may be confused for an IUP on ultrasound and asymmetric thinning of the myometrial wall surrounding the IUP helps differentiate a true IUP from a cornual pregnancy. What other information can the pelvic ultrasound provide in the diagnosis? How can you confirm the additional information? A pelvic ultrasound may also identify fluid in the posterior cul-de-sac or in the adnexa. This fluid may be indicative of intraabdominal bleeding or ruptured corpus luteum cyst. To differentiate, a culdocentesis may be performed. How is a positive and negative culdocentesis defined? A culdocentesis is positive when the fluid aspirated is non-clotted blood. A culdocentesis is truly negative only if straw colored fluid is aspirated. If clotted blood is aspirated or nothing is aspirated with an ultrasound finding of moderate to large amounts of cul de sac fluid, then the culdocentesis is equivocal and does not rule out the possibility of a ruptured ectopic pregnancy. This may indicate one of the following: theres not enough fluid in the posterior cul-de-sac to be aspirated, the needle was not pushed far enough, or you may have stuck the needle into a small vessel. Why is non-clotted blood aspirated during a positive culdocentesis? The blood aspirated during a positive culdocentesis does not clot because all the clotting factors have been used up while the blood pooled in the posterior cul-de-sac over time. How do you perform a culdocentesis? A culdocentesis can be performed in the ER, or in the office as an adjunct diagnostic tool. After doing a gentle bimanual exam to determine the orientation of the uterus, a speculum is placed in the vagina, opened wide enough to visualized the posterior fornix. The cervix and fornix are then prepped with betadine. After aspirating about 2-4 cc of 1% lidocaine without epinephrine into your syringe, using a 21 gauge spinal needle or 18-20 gauge angiocath needle on a 10 cc syringe, draw up 4 cc of 1% lidocaine. Inject 2cc of lidocaine into the posterior lip of the cervix then place a single tooth tenaculum at your injection site. Lifting the cervix upward, inject the remainder of the lidocaine into the posterior fornix mucosa, about 1-2 cm under the cervix aiming directly into the midline. After injecting the vaginal fornix mucosa, slowly advance the needle into the pouch of Douglas at a 20-30 degree posterior angle, pulling back on the syringe plunger to create a vacuum. If you have advanced 2cm into the cul-de-sac space without return of fluid or blood, have the patient raise herself on her elbows if possible, to direct the fluid towards the cul-de-sac. If still no return, withdraw needle slowly with continued vacuum on the syringe. Based on the information provided, how would you manage this patient? It is important to assess her plans for this pregnancy as well as plans for future fertility, as this will influence your counseling and management options for presumed ectopic pregnancy. Stress the importance of following up regardless of the management course chosen. Management options include: 1. Perform culdocentesis and proceed with surgical intervention if culdocentesis is positive. If she does not desire to proceed with this pregnancy and desires permanent sterilization, consider salpingectomy with contra lateral tubal occlusion or bilateral salpingectomy with D&C if an ectopic is not visualized. 2. Repeat serum hCG in 48 hours if the patient is clinically stable and is deemed responsible and reliable. This is the best option for the stable patient who strongly desires the pregnancy. 3. Consider 23 hr observation if the pregnancy is desired but patient is deemed unreliable and/or clinical exam is not completely benign and/or concomitant vaginal bleeding. Re-checking serum hCG in 12 hours may be helpful only if the hCG levels drop or plateau.

4. Treat with methotrexate +/- uterine evacuation (vigorous endometrial biopsy or suction curettage) if you do not suspect rupture and if it is an unwanted pregnancy. Some feel strongly that methotrexate should not be used unless abnormal pregnancy has been confirmed either with hCG (inappropriate rise, plateau, or negative IUP on ultrasound despite sufficient serum hCG levels) or pathology of uterine contents. However, delay resulting from checking serial serum hCG levels to document an abnormal pregnancy may result need for surgical intervention due to ectopic rupture and significant financial expense to the patient. Patients wishes regarding current pregnancy as well as future fertility should be considered as you discuss the pros and cons of all management options with the patient. At a minimum, this patient should have a repeat serum beta-hCG in 48 hours to assess whether she may have an abnormal pregnancy, even though her serum beta-hCG is low. References 1. Taylor KE. Adnexal Masses. In C.S. Havens & N.D. Sullivan, (Ed.), Manual of Outpatient Gynecology. (p192- 193). Philadelphia, PA: Lippincott Williams & Wilkins. 2. Medical Management of Tubal Pregnancy, ACOG Practice Bulletin Number 3, ACOG Compendium 2005.