See: [Rosen's Ectopic pregnancy](x-devonthink-item://2EDF4F0B-04B3-4DB8-A54E-A5775713FD62?page=2&start=6601&length=17&search=Ectopic%20Pregnancy), [Dunn Ectopic pregnancy](x-devonthink-item://29569E0C-EF9D-42D3-A63C-8A110DD0A29F) guidelines RWH: [RWH ectopic management](x-devonthink-item://AB4BEDF6-BCDD-4733-A4A6-093DDC57487D) See also: [[miscarriage and threatened miscarriage]] > [!key points] > - **HCG** > - \>5000, should see IUP on *trans-abdominal* USS if present (discriminatory zone) > - \>1500, should see IUP in *transvaginal* USS if present (4.5 weeks gestation) > - \>15000 should see cardiac activity > - ==USS findings of IUP:== > - Definitive evidence of an IUP is a gestational sac containing a *yolk sac* in two planes within the endometrium which usually occurs around 5-6 weeks gestational age > - note, a gestatinal sac becomes visible earlier, but 10-20% of ectopics can have a pseudo-gestational sac, so this does not confirm IUP > - 1/30,000 chance of ectopic if intrauterine pregnancy confirmed (1/3000 in *fertility-assisted pregnancies*) > - **Clinically likely features:** > - shoulder pain > - severe pain > - syncope > - acute abdomen / shock > [!key points] Risk factors for ectopic pregnancy > - Tubal surgery (for tubal sterilization or ectopic pregnancy) > - [[Pelvic inflammatory disease|PID]] > - Smoking > - Advanced age > - Prior spontaneous abortion > - Medically induced abortion > - History of infertility > - Intrauterine device > - prior ectopic > - endometriosis > [!warning] important > an empty uterus and free pelvic fluid is highly suggestive of ectopic (but an empty uterus only can just be due to early pregnancy) # Assessment ![[Pasted image 20240311164812.png| ectopic locations]] ## Ultrasound see [ASUM first trimester ultrasound guideline](x-devonthink-item://1C05DA8F-DE0E-4EF1-94AE-1151CB53828E) #pocus ![[Pasted image 20231119221120.png]] ![[Pasted image 20231119221145.png]] ![[Pasted image 20231119220644.png]] ![[Pasted image 20231119221327.png]] # management > [!treatment] Indications for surgical management: > - haemodynamically unstable > - intraperitoneal bleeding (eg peritonitic, USS) > - fetal heart activity on USS > - adnexal mass >3.5 cm > - **HCG ≥ 3500** > - Moderate-to-severe pelvic pain > - contraindications to medical management > [!doses] Indications for medical management > - stable > - no contraindications to methotrexate > - normal LFT, UEC, FBC (no bone-marrow impairment) > - no aplastic anaemia, active liver disease, etc > - unruptured mass <3.5cm > - HCG <3500 > - will use reliable contraceptive for 3 months from lass methotrexate use > - no significant blood in peritoneal cavity or pouch of douglas > - no co-existing intrauterine pregnancy > - not currently breast-feeding ## surgery - prefer to preserve tube if possible (not always possible) - salpingostomy or salpingotomy if unruptured tubal pregnancy <4mm in diameter - salpingectomy if tube damaged, uncontrolled bleeding, recurrent ectopic same tube, size >5cm ## methotrexate may be suitable for early unruptured tubal pregnancies ## stable patient with first-trimester vaginal bleeding see also [[miscarriage and threatened miscarriage|early pregnancy bleeding]] ![[Pasted image 20231118133348.png| Rosen guideline]] ![[Pasted image 20231119222833.png|Ma and Mateer guideline is similar]] # Related Questions ## ectopic - [ ] 2Q: [First Trimester Bleeding](x-devonthink-item://0987D972-A221-4F8A-B7D7-B0DCC349A2B3?page=8) -- [Answer](x-devonthink-item://C7FCB01A-E668-44AF-8C95-C298A40F8D68?page=6) ## ectopic pregnancy - [ ] 3Q: [Ectopic Pregnancy](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=8) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=4) - [ ] 4Q: [Abdominal Pain and Collapse](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=2) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=1) -- [prop](x-devonthink-item://B3E266DE-B0B2-4F19-9986-B7C6FD455008?page=1)