Life Threatening Differential Diagnosis
<20w GA
Ruptured ectopic pregnancy
Retained products of conception
Complication of pregnancy termination
Septic abortion
>20w GA
Placental abruption
Placenta previa
Uterine prolapse
Postpartum hemorrhage
Vasa previa
Other Genital Tract Causes
Acute severe menorrhagia
Genitourinary trauma
Uterine arteriovenous malformations
Emergency department evaluation algorithm for vaginal bleeding
Ectopic Pregnancy
Pathophysiology
Implantation occurring outside of uterus
Locations
Fallopian Tubes (>90%)
Abdomen (1%)
Cervix (1%)
Ovary (1-3%)
Cesarean Scar (1-3%)
Risk Factors
History of ectopic pregnancy
Previous trauma/injury to fallopian tubes (ascending pelvic infections, prior pelvic/uterine/fallopian tube surgeries)
Fertility treatment
History of infertility
cigarette smoking
age >35
Presentation
History
abdominal/pelvic pain
vaginal bleeding
syncope
Physical findings
abdominal tenderness to palpation
vaginal bleeding
hemodynamic instability
tachycardia
hypotension
pallor
Diagnosis
Transvaginal ultrasound
gestational sac with a yolk sac, embryo, or both is noted in the adnexa
Visualization of a definitive intrauterine pregnancy eliminates ectopic pregnancy EXCEPT in the rare case of a heterotopic pregnancy
If intrauterine pregnancy is not identified, nor adnexal mass, the results are equivocal and patient should follow-up in two days for a repeat ultrasound and serum hCG
Serum hCG level Discriminatory Level
hCG value above which the landmarks of a normal intrauterine gestation should be visible on ultrasonography
Absence of ultrasound findings of normal intrauterine gestation in the presence of an hCG level above the discriminatory level strongly suggests nonviable gestations (ie early pregnancy loss or an ectopic pregnancy)
literature describes discriminatory level ranging between 1500-3500, with cases noted to be even lower
average increase of hCG level is approximately:
49% for an initial hCG level <1500
40% for an initial hCG level 1500-3000
33% for an initial hCG level >1500
Treatment
Methotrexate
Surgical Management
RhoGam if patient is Rh negative
References
ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy. Obstetrics & Gynecology 131(2):p e65-e77, February 2018. | DOI: 10.1097/AOG.0000000000002464
Barnhart KT, Guo W, Cary MS, et al. Differences in Serum Human Chorionic Gonadotropin Rise in Early Pregnancy by Race and Value at Presentation. Obstet Gynecol. 2016;128(3):504-511. doi:10.1097/AOG.0000000000001568
Borhart JC. Approach to the adult with vaginal bleeding in the emergency department. UpToDate. Accessed November 3, 2023. https://www.uptodate.com/contents/approach-to-the-adult-with-vaginal-bleeding-in-the-emergency-department.
Erin Mosher, DO