Clinical Approaches to Hospital Medicine by Kevin Conrad

Author:Kevin Conrad
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Bleeding Secondary to Ectopic Pregnancy

Ectopic pregnancy is another common cause of first trimester bleeding. Ectopic pregnancy occurs when an embryo has implanted in a site outside the uterus. The most common site of extrauterine pregnancy is the ampulla of the fallopian tube [9]. As the embryo grows, it can cause expansion or rupture of the fallopian tube, resulting in vaginal or intra-abdominal bleeding. Any patient with a confirmed pregnancy that presents with vaginal bleeding should be evaluated for the location of pregnancy (i.e., extrauterine vs. intrauterine) as ruptured ectopic pregnancy is a surgical emergency. Patients with a ruptured ectopic pregnancy may present with diffuse abdominal pain or peritoneal signs.Ectopic pregnancy can be diagnosed with a beta-hCG level that is greater than 2000 IU/L in the setting of a transvaginal ultrasound that shows an absent intrauterine pregnancy [10]. A non-ruptured ectopic pregnancy can be managed medically or surgically. Methotrexate is the gold standard for medical management. Absolute contraindications include hemodynamically instability, active liver disease, and unreliable patient. Relative contraindications include a beta-hCG of >5000 IU/L, gestational sac >3.5 cm, or the presence of fetal cardiac activity [11]. Surgical intervention is recommended when the criteria for medical management are not met. The surgical approach can be laparoscopic or via a laparotomy. The surgical approach should be determined based on the experience of the surgeon with each skill as well as the stability of the patient. Once the approach is determined, surgical treatment can be a salpingectomy or salpingostomy. Salpingostomy may be preferred for women who desire to maintain fertility. However, the risk of ectopic pregnancy in future pregnancies is increased [12]. Salpingectomy is necessary when the fallopian tube is ruptured.

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