Rachel K. Love and Nicole Calloway Rankins
History of present illness
A 23-year-old gravida 1 woman presents to the ultrasound clinic for afirst-trimester dating ultrasound. By an unsure last menstrual period, she is approximately 10 weeks’ pregnant.
Her pregnancy thus far has been uncomplicated, with the exception of intermittent vaginal spotting for which she did not seek medical attention. Her past medical history is remark- able for asthma, and she has had no prior surgery. Her gyne- cologic history is significant for pelvic inflammatory disease at age 18, which was successfully treated on an outpatient basis.
The transvaginal ultrasound reveals a normal-sized anteverted uterus with no evidence of an intrauterine pregnancy. Her right adnexa contains a mass consisting of a gestational sac and fetal pole with cardiac activity (Fig. 35.1). At the end of her ultrasound appointment, she suddenly develops writhing abdominal pain and dyspnea. Immediate repeat ultrasound reveals a largefluid collection in the posterior cul-de-sac. She is urgently transported to the emergency department for further management.
Physical examination
General appearance:Well-nourished young woman in apparent distress from pain, diaphoretic
Vital signs:
Temperature: 36.0°C Pulse: 95 beats/min
Blood pressure: 69/43 mmHg Respiratory rate: 22 breaths/min Oxygen saturation: 100% on room air
Respiratory:Increased respiratory rate, lungs clear to auscultation bilaterally
Cardiovascular:Mildly tachycardic, regular rhythm, no murmurs
Abdomen:Moderately distended, tender to light palpation in all four quadrants, rebound and guarding present Pelvic:Deferred
Extremities:No edema, nontender Laboratory studies:
Hb: 10.5 g/dL (2 days prior to presentation: Hb 13.5 g/dL) Blood type: O positive
What is your diagnosis?
This patient has a ruptured ectopic pregnancy. Her diagnosis was made clinically based on the presence of peritoneal signs,
hypotension, acute drop in hemoglobin concentration, and ultrasonographic evidence of hemoperitoneum in the setting of a known ectopic pregnancy.
How would you manage this patient?
This patient warrants rapid hemodynamic stabilization and prompt surgical treatment. She was placed on continuous vital sign monitoring, given two large bore intravenous catheters, and was administered a 2-L bolus of normal saline. A blood sample was sent for type and screen and complete blood count.
She was consented for surgery and was emergently taken to the operating room where a diagnostic laparoscopy was performed. Findings during laparoscopy were significant for 2.5 L of blood in the peritoneal cavity, and a large right tubal pregnancy containing an intact fetus of approximately 9 weeks’ gestation (Fig. 35.2). A laparoscopic right salpingectomy was performed using a laparoscopic vessel-sealing device without complications. Intraoperative hemoglobin was checked and returned to 7.2 g/dL. She was transfused 1 U of packed red blood cells in the recovery room for symptomatic acute blood loss anemia. Her hemoglobin on the morning of postoperative day 1 rose appropriately to 8.2 g/dL. She otherwise had an uncomplicated postoperative course and was discharged home on postoperative day 1. Prior to discharge she was counseled regarding ectopic pregnancy and the implications for future pregnancy. Surgical pathology confirmed products of conception.
Ruptured ectopic pregnancy
Ectopic pregnancy accounts for 1–2% of all pregnancies in the United States yet accounts for approximately 6% of all pregnancy-related deaths [1,2]. Although the incidence of ectopic pregnancy is becoming harder to estimate due to the number of cases treated as an outpatient, it still remains the leading cause of pregnancy-related mortality in the first trimester. Ninety-three percent of deaths associated with ectopic pregnancy are caused by hemorrhage [2]. Hence, it is imperative for the clinician to maintain a high index of suspicion for ectopic pregnancy in any sexually active reproductive-aged female presenting with abdominal pain and/or vaginal bleeding, and a urine pregnancy test should be obtained in the initial evaluation.
The risk factors for ectopic pregnancy are directly related to tubal damage and inflammation. These risk factors include prior ectopic pregnancy, prior tubal surgery, history of pelvic
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
inflammatory disease,Chlamydia trachomatisinfection, and in utero diethylstilbestrol (DES) exposure [3].
Conversely, risk factors for tubal rupture in ectopic preg- nancy are not as clearly outlined and are contradictory in retrospective cohort studies. In one retrospective cohort study of 693 ectopic pregnancies, tubal rupture was encountered more often in women with no history of ectopic pregnancy, and there was no correlation between serum beta-human chorionic gonadotropin (beta-hCG) levels and tubal rupture [4]. Furthermore, in 11% of the cases of tubal rupture, the beta-hCG level was less than 100 mIU/mL. In a French- population-based study, the following were identified as risk factors for tubal rupture: ovulation induction, beta-hCG levels exceeding 10 000 mIU/mL at the time ectopic pregnancy was suspected, never having used contraception, and a history of tubal damage in combination with infertility [5]. A case- control study conducted in Amsterdam identified no patient-
related risk factors for severe intra-abdominal hemorrhage in women with tubal ectopic pregnancy (severe hemorrhage was defined as receiving transfusion of four or more units of packed red blood cells) [6]. However, the study did identify that substandard care was more often associated with cases of severe hemorrhage. Misdiagnosis, in which the provider incorrectly identified an ectopic pregnancy as an intrauterine pregnancy on transvaginal ultrasound, was the most common reason for substandard care in the women with severe hemor- rhage. In summary, the results of the above studies illustrate a lack of consistent predictors for tubal rupture and severe hemorrhage, so providers must maintain an acute awareness for ectopic pregnancy. In cases of known ectopic pregnancy or pregnancies of unknown location, providers must counsel their patients on the signs and symptoms of tubal rupture and advise patients to seek immediate medical attention in such cases.
Most ectopic pregnancies occur in the fallopian tube, and the most common site of tubal implantation is the ampullary region. The rate of tubal rupture in ectopic pregnancy ranges from 18 to 34% [4,5]. Pregnancies implanted in the isthmic or ampullary regions tend to rupture earlier, while cornual and interstitial implantations tend to rupture later. Rupture is usually spontaneous, but may be precipitated by coitus or by bimanual examination. Clinical signs and symptoms of ruptured ectopic pregnancy may include abdominal pain with rebound tenderness, referred shoulder pain, cervical motion tenderness, hypotension, and tachycardia. Laboratory values assisting in the diagnosis of rupture are a low initial hemoglobin concentration or a rapidly decreasing hemo- globin concentration. In a ruptured ectopic pregnancy, transvaginal ultrasound will reveal fluid in the posterior cul-de-sac, and if the bleeding is severe, transabdominal
Fig. 35.2 Laparoscopicfindings with hemoperitoneum and right tubal ectopic pregnancy.
Fig. 35.1 Ultrasoundfindings with gestational sac and fetal pole in right adnexa.
Case 35: A 23-year-old pregnant woman with acute-onset abdominal pain and hypotension
ultrasound will displayfluid in the subhepatic recess and the paracolic gutters.
Once the diagnosis of ruptured ectopic pregnancy is made, the treatment is urgent surgical intervention. Medical management with methotrexate is contraindicated in this setting. Initial stabilization measures in the case of massive hemoperitoneum or shock include obtaining two large bore intravenous catheters, intravenous fluid resuscitation with isotonicfluids, blood transfusion if necessary, administering supplemental oxygen, keeping the patient warm, and ele- vating the legs or placing the patient in Trendelenburg position.
Surgical treatment is accomplished by salpingectomy (removing the tube) or salpingostomy (incising the tube and removing the ectopic pregnancy tissue with conservation of the tube). Both salpingectomy and salpingostomy can be per- formed via laparoscopy or laparotomy. A Cochrane review of 35 studies analyzing the treatment for ectopic pregnancy found that laparoscopy was feasible and less costly than open surgery [7], and is generally the preferred approach. In cases of severe intraperitoneal hemorrhage, hemodynamic instability, or inadequate visualization at the time of laparoscopy, laparot- omy may be warranted. Laparoscopic salpingostomy is less successful than open salpingostomy in the elimination of the ectopic pregnancy because of higher rates of persistent tropho- blastic tissue, but long-term follow-up shows no difference in intrauterine pregnancy rates [7]. The decision to perform a salpingostomy versus a salpingectomy is often made by the provider at the time of surgery. Factors that may influence this decision include the extent of tubal damage, appearance of the contralateral fallopian tube, desire for future childbearing, prior ectopic pregnancy on the ipsilateral side as the current ectopic pregnancy, and surgeon skill. In cases where salpin- gostomy is performed, postoperative monitoring of beta-hCG
levels is required as persistent trophoblastic tissue remains in the fallopian tube in 5–20% of women [8].
An important component of all ectopic pregnancy treatment is appropriate patient counseling. A prior ectopic pregnancy increases the risk for an ectopic with future preg- nancy [3]; therefore, it is imperative that patients be counseled to present as soon as possible with future pregnancy recogni- tion. Finally, if a patient is Rh negative, she should receive anti- D immune globulin as part of her treatment.
Key teaching points
Ectopic pregnancy is the number one cause of maternal mortality in thefirst trimester, and hemorrhage from rupture accounts for greater than 90% of these deaths.
Ruptured ectopic pregnancy is a gynecologic emergency that requires prompt diagnosis and surgical treatment.
Beta-human chorionic gonadotropin (beta-hCG) levels have not been shown to consistently correlate with risk of tubal rupture, and tubal rupture can occur even when the beta-hCG level is low.
Medical management with methotrexate is absolutely contraindicated in the setting of ruptured ectopic pregnancy.
In general, laparoscopy is the preferred surgical approach for management. However, laparotomy may be needed in times of hemodynamic instability or inadequate
visualization at the time of laparoscopy.
Patients should be counseled regarding the importance of presenting for care as soon as possible after recognition of pregnancy in the future, as prior ectopic pregnancy increases the risk for future ectopic pregnancy.
Patients with ectopic pregnancy who are Rh negative should receive anti-D immune globulin.
References
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2. Centers for Disease Control and Prevention. Pregnancy-related mortality surveillance–United States, 1991–1999.MMWR Surveill Summ 2003;52:1–9.
3. Ankum WM, Mol BW, Van de Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis.Fertil Steril 1996;65:1093–9.
4. Saxon D, Falcone T, Mascha EJ, et al.
A study of ruptured tubal ectopic pregnancy.Obstet Gynecol1997;
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379–87.