0071643192.pdf

OBSTETRICS AND GYNECOLOGY

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■ A modern copper IUD does not increase the risk of ectopic compared to

no contraception, but if a women becomes pregnant with an IUD, then

the risk of ectopic is high (approximately 3%).

SYMPTOMS

■ Abdominal pain

■ Vaginal bleeding—common, but not always present

■ Dizziness or syncope (less common)

EXAM

■ Vital signs may be normal or hypotension may be present due to hemor-

rhagic shock.

■ A relative bradycardia may be present secondary to vagal stimulation.

■ The pelvic/abdominal exam may be normalor can have localized tender-

ness including CMT.

■ Adnexal tenderness or adnexal mass may not always be present on exam.

DIFFERENTIAL

The differential for a woman of childbearing age with abdominal/pelvic pain

or abnormal vaginal bleeding includes:

■ Ectopic pregnancy ■ Mittelschmerz

■ Appendicitis/cholecystitis ■ Intrauterine pregnancy

■ Ovarian cyst/torsion ■ Threatened abortion

■ PID ■ Inevitable abortion

■ Endometriosis ■ Molar pregnancy

■ UTI/renal colic ■ Heterotopic pregnancy

■ Inflammatory bowel disease (IBD) ■ Corpus luteum cyst

DIAGNOSIS

■ Ectopic pregnancy should be considered in all women of childbearing age

who present with abdominal or pelvic pain, especially those with unex-

plained signs/symptoms of hypovolemia.

■ Positive pregnancy test is an almost universal finding in the diagnosis of ec-

topic (very dilute urine or switched urine samples may lead to a false nega-

tive!).

■ Ultrasound is the test of choice in evaluating pregnant patients with com-

plaints consistent with ectopic pregnancy (see Figure 12.2).

■ The finding of a yolk sac, a double decidual sac, or fetal cardiac activity

inside the uterus is considered diagnostic for IUP. A gestational sac alone

is not diagnosticfor IUP because it may be confused with a pseudosac,

which is often present in patients with extrauterine pregnancy.

■ Aβ-hCG facilitates ultrasound interpretation. The “discriminatory zone”

(theβ-hCG level above which an IUP should be visualized by ultrasound)

for transvaginal ultrasound is 1000–1500 IU/mL; for transabdominal ultra-

sound it is about 4000–6500 IU/mL.

■ Above the discriminatory zone, it should be possible to identify an IUP.

Failure to do so mandates OB/GYN consultation for presumed ectopic.

■ Aβ-hCG level below the discriminatory zone and an ultrasound that fails

to show an intrauterine pregnancy is consistent with either an early IUP or

an ectopic pregnancy.

■ Heterotopic pregnancy must be considered in unstable patients with find-

ings diagnostic for IUP. Look at the adnexa and look for signs of simultane-

ous ectopic pregnancy or free fluid.

All females of childbearing

age with abdominal pain

should be presumed pregnant

until proven otherwise.

Classic triad for ectopic

pregnancy:

Abdominal pain

Vaginal bleeding

Positive pregnancy test

Mittelschmerz: Midcycle

(half-way between periods)

pain associated with

ovulation, usually sharp,

usually on one side