4/25 9AM Ectopic Pregnancy and Spontaneous Abortion

Patient Presentation

• Patient Profile: 36-year-old Female, G1 P0
• Symptoms:
  • Light vaginal bleeding
  • Mild right lower quadrant pain (rated 2/10)
  • Intermittent, crampy pain, not related to urination
  • No nausea or vomiting
• Bowel Movement: Normal, no blood or black color
• Medical History:
  • No allergies
  • No medications
  • History of two hospitalizations:
  • Lower abdominal pain (8 years ago, resolved with antibiotics, presumed PID)
  • Left ectopic pregnancy (surgical removal needed)

Social History

• Mutual monogamous relationship, no contraception used
• Recent loss of primary residence due to fire, currently staying with a friend

Physical Examination

• General: Anxious appearance

• Vital Signs:

  • Temperature: 98.6°F
  • Blood Pressure: 105/62 mmHg
  • Pulse: 95 bpm

• Abdominal Exam:

  • Normal bowel sounds
  • Mild tenderness in the right lower quadrant, no mass or distension

• Pelvic Exam:

  • Right adnexal tenderness;
  • Normal uterus size;
  • Cervical motion tenderness;
  • Negative rectal exam with heme-negative stool

Differential Diagnoses

1. Gynecological:
   • Recurrence of Pelvic Inflammatory Disease (PID)
   • Ectopic Pregnancy
   • Ovarian cysts
   • Ovarian torsion
   • Spontaneous abortion
2. Gastrointestinal:
   • Appendicitis
   • Constipation
3. Urological:
   • Cystitis
   • UTI
   • Kidney stone
4. Other:
   • Endometriosis

Ectopic Pregnancy

• Most Common Symptoms:
  • Abdominal pain (95-100% of cases)
  • Abnormal vaginal bleeding (65-85%)
  • Amenorrhea if patient has missed periods
  • Tenderness during pelvic examination, particularly adnexal tenderness
• Risk Factors:
  • Previous ectopic pregnancy (10x higher risk)
  • History of PID (increased morbidity due to chronic inflammation)
  • Use of IUD
  • In vitro fertilization (IVF)
  • Tubal surgery or abnormal anatomy (e.g., endometriosis)
  • Advanced maternal age (>35 years)

Locations of Ectopic Pregnancies

• Most commonly in fallopian tubes:
  • Ampulla (80% cases)
  • Isthmus (12%)
  • Interstitial (2%)
• Less common locations include:
  • Cervix
  • Abdominal cavity
  • Ovaries (rare, challenging to treat)
• Ectopic pregnancies outside tubes are usually more complex surgeries

Initial Management Steps

1. Testing:
   • Urine pregnancy test (cheap, fast results)
   • Follow up with serum beta-hCG
   • Transvaginal ultrasound (to confirm location of pregnancy)
2. Follow-up:
   • Beta-hCG levels should typically double in 48 hours if a normal pregnancy
   • If not doubling, consider ectopic or fetal loss

Ectopic Treatment Options

• Medical:
  • Methotrexate (folate antagonist, indicated for stable ectopics)
  • Monitor HCG levels post-treatment
• Surgical:
  • Salpingectomy (removal of entire tube)
  • Salpingostomy (preserving the tube)
• Expectant Management:
  • Rarely recommended; patients need strong follow-up capabilities

Spontaneous Abortion Types

1. Threatened: Bleeding with closed cervix.
2. Inevitable: Open cervix with contents likely to pass.
3. Incomplete: Some tissue passed, cervix open.
4. Complete: All contents expelled, cervix can be closed.
5. Missed: Closed cervix, fetus not viable.

Treatment of Spontaneous Abortion

1. Surgical: D&C, vacuum aspiration, or manual vacuum aspiration in the office.
2. Medical: Misoprostol (with or without mifepristone).
3. Expectant Management: Observe and allow natural passage of tissue, patient education on signs of complications.

Complications and Considerations

• Be vigilant about the risk of septic abortion (fever, tachycardia, hypotension).
• Monitor for Rh status, especially if Rh-negative, administer RhoGAM if indicated.
• Address and consider any psychological and social ramifications of pregnancy loss with patients.

Follow-Up Care

• Ensure follow-up appointments are accessible and manageable for patient circumstances.
• Consider social factors that may complicate the management and ensure clear communication is paramount in treatment options delivery.