WHAT’S THE VERDICT?
A defense verdict is returned.
Medical considerations
The incidence of ectopic pregnancy is 2% of all pregnancies, with a higher incidence (about 4%) among infertility patients.1 Up to 10% of ectopic pregnancies have no symptoms.2
Clinical presentations. Classic signs of ectopic pregnancy include:
- abdominal pain
- vaginal bleeding
- late menses (often noted).
A recent case of ectopic pregnancy presenting with chest pain was reported.3 Clinicians must never lose site of the fact that ectopic pregnancy is the most common cause of maternal mortality in the first trimester, with an incidence of 1% to 10% of all first-trimester deaths.4
Risk factors include pelvic inflammatory disease, as demonstrated in the opening case. “The silent epidemic of chlamydia” comes to mind, and tobacco smoking can adversely affect tubal cilia, as can pelvic adhesions and/or prior tubal surgery. All of these factors can predispose a patient to ectopic pregnancy; in addition, intrauterine devices, endometriosis, tubal ligation (or ligation reversal), all can set the stage for an ectopic pregnancy.5 Appropriate serum hCG monitoring during early pregnancy can assist in sorting out pregnancies of unknown location (PUL; FIGURE). First trimester ultrasonography, at 5 weeks gestation, usually identifies early intrauterine gestation.
Imaging. With regard to pelvic sonography, the earliest sign of an intrauterine pregnancy (IUP) is a sac eccentrically located in the decidua.6 As the IUP progresses, it becomes equated with a “double decidual sign,” with double rings of tissue around the sac.6 If the pregnancy is located in an adnexal mass, it is frequently inhomogeneous or noncystic in appearance (ie, “the blob” sign); the positive predictive value (PPV) is 96%.2 The PPV of transvaginal ultrasound is 80%, as paratubal, paraovarian, ovarian cyst, and hydrosalpinx can affect the interpretation.7
Heterotopic pregnancy includes an intrauterine gestation and an ectopic pregnancy. This presentation includes the presence of a “pseudosac” in the endometrial cavity plus an extrauterine gestation. Heterotopic pregnancies have become somewhat more common as ART/IVF has unfolded, especially prior to the predominance of single embryo transfer.
Managing ectopic pregnancy
For cases of early pregnancy complicated by intermittent bleeding and/or pain, monitoring with serum hCG levels at 48-hour intervals to distinguish a viable IUP from an abnormal IUP or an ectopic is appropriate. The “discriminatory zone” collates serum hCG levels with findings on ultrasonography. Specific lower limits of serum hCG levels are not clear cut, with recommendations of 3,500 mIU/mL to provide sonographic evidence of an intrauterine gestation “to avoid misdiagnosis and possible interruption of intrauterine pregnancy,” as conveyed in the American College of Obstetricians and Gynecologists 2018 practice bulletin.8 Serum progesterone levels also have been suggested to complement hCG levels; a progesterone level of <20 nmol/L is consistent with an abnormal pregnancy, whereas levels >25 nmol/L are suggestive of a viable pregnancy.2 Inhibin A levels also have been suggested to be helpful, but they are not an ideal monitoring tool.
While most ectopic pregnancies are located in the fallopian tube, other locations also can be abdominal or ovarian. In addition, cesarean scar ectopic pregnancy can occur and often is associated with delay in diagnosis and greater morbidity due to such delay.9 With regard to ovarian ectopic, Spiegelberg criteria are established for diagnosis (TABLE 1).10
Appropriate management of an ectopic pregnancy is dependent upon the gestational age, serum hCG levels, and imaging findings, as well as the patient’s symptoms and exam findings. Treatment is established in large part on a case-by-case basis and includes, for early pregnancy, expectant management and use of methotrexate (TABLE 2).11 Dilation and curettage may be used to identify the pregnancy’s location when the serum hCG level is below 2,000 mIU/mL and there is no evidence of an IUP on ultrasound. Surgical treatment can include minimally invasive salpingostomy or salpingectomy and, depending on circumstance, laparotomy may be indicated.
Fertility following ectopic pregnancy varies and is affected by location, treatment, predisposing factors, total number of ectopic pregnancies, and other factors. Ectopic pregnancy, although rare, also can occur with use of IVF. Humans are not unique with regard to ectopic pregnancies, as they also occur in sheep.12
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