Population: Women with ectopic pregnancy.
Organizations
NICE 2019, ACOG 2017
Recommendations
Evaluation
–Transvaginal ultrasound (TVUS) with a crown-rump length ≥7 mm but no cardiac activity.
• Repeat ultrasound in 7 d.
• Quantitative beta-hCG q 48 h × 2 levels.
–TVUS with gestational sac ≥25 mm and no fetal pole.
• Repeat ultrasound in 7 d.
• Quantitative beta-hCG q 48 h × 2 levels.
Management
–Differentiate early intrauterine pregnancy loss from ectopic pregnancy:
–Uterine aspiration to identify presence of chorionic villi (indicate intrauterine pregnancy).
–If chorionic villi not confirmed, monitor hCG levels:
• Take first level 12–24 h after aspiration.
• Plateau/increase in hCG suggests incomplete evacuation or nonvisualized ectopic warranting further treatment.
• Decrease in hCG suggests failed intrauterine pregnancy; monitor with serial hCG measurements.
–Methotrexate candidates:1
• No significant pain.
• Adnexal mass <3.5 cm.
• No cardiac activity on TVUS.
• Beta-hCG <5000 IU/L.
• Dose is 50 mg/m2 IM.
–Laparoscopy if:
• Unstable patient.
• Severe pain.
• Adnexal mass ≥3.5 cm.
• Cardiac activity seen.
• Beta-hCG ≥5000 IU/L.
–Rhogam 250 IU to all Rh-negative women who undergo surgery for an ectopic.
Practice Pearls
• Ectopic pregnancy can present with:
- Abdominal or pelvic pain.
- Vaginal bleeding.
- Amenorrhea.
- Breast tenderness.
- GI symptoms.
- Dizziness.
- Urinary symptoms.
- Rectal pressure.
- Dyschezia.
• Most normal intrauterine pregnancies will show an increase in beta-hCG level by at least 63% in 48 h.
• Intrauterine pregnancies are usually apparent by TVUS if beta-hCG >1500 IU/L.
Sources
–www.guidelines.gov/content.aspx?id=39274
–NICE. Ectopic pregnancy and miscarriage: diagnosis and initial management (NG126). 2019.
–Obstet Gynecol. 2018 Feb;131(2):e65-e77.