Overview
Definition
Implantation of the fertilized ovum outside the uterine cavity, most commonly in the fallopian tube.
Epidemiology
Occurs in ~2% of all pregnancies. The leading cause of maternal death in the first trimester.
Etiology & Risk Factors
- Conditions that slow or block tubal transport: Pelvic Inflammatory Disease (PID), prior ectopic, tubal surgery, endometriosis
- IUD use (does not cause ectopic, but if pregnancy occurs with an IUD, it is more likely to be ectopic)
Clinical Symptoms
- Classic Triad: Abdominal/pelvic pain, Vaginal bleeding, and Amenorrhea (missed period)
- If ruptured: Severe unilateral pain, syncope, shoulder pain (Kehr's sign - from diaphragmatic irritation by hemoperitoneum), hemodynamic instability
Clinical Approach
Diagnosis
- Urine or Serum beta-hCG: Positive
- Transvaginal Ultrasound: Absence of intrauterine pregnancy (IUP) when beta-hCG is above the discriminatory zone (~1500-2000 mIU/mL), or direct visualization of an adnexal mass/yolk sac outside the uterus
Management
- Hemodynamically Unstable (Ruptured): EMERGENT exploratory laparotomy or laparoscopy (Salpingectomy)
- Hemodynamically Stable (Unruptured, mass < 3.5cm, no fetal heartbeat, hCG < 5000): Methotrexate (folic acid antagonist) to halt trophoblastic cell growth
Complications
- Tubal rupture
- Hemorrhagic shock and death
- Decreased future fertility