HWN Suggests

Rule Out Ectopic in the Emergency Department

In contrast to what most of us were taught, the index beta HCG measurement does not discriminate among ectopic pregnancy, failed/failing intrauterine pregnancy, and early/healthy intrauterine pregnancy with sufficient accuracy to guide decision-making. Put more simply, the beta does not help you. If the ultrasound shows no IUP or ectopic, do not be reassured by a low beta and do not be alarmed by a high beta. The patient may have a healthy IUP, she may have a nonviable IUP that is miscarrying or will miscarry, or she may have an ectopic pregnancy; the beta doesn’t make any of these three diagnoses more or less likely enough to be a useful test to us, on the index visit. This is not controversial,…

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  Methotrexate

Methotrexate (MTX): MTX is a folic acid antagonist that is up to 95% effective in appropriate patients (BhCG <5000, no fetal cardiac activity, ectopic mass <3–4cm, hemodynamically stable, no sign of rupture, reliable patient.). Failure of MTX is related to BhCG level: Failure rates are approx. 15% with BhCG >5000 and 5% with BhCG <5000. Prior to MTX treatment, blood tests must confirm normal liver and kidney function, and patients must be counseled to avoid folic acid and alcohol. Strenuous exercise and intercourse must also be avoided due to the risk of tubal rupture. Patients must also discontinue folic acid supplementation.

 Ectopic Pregnancy Pitfalls in Diagnosis

Ruling out ectopic pregnancy based on BhCG level. There is no BhCG level or series of BhCG levels at which ectopic can be ruled out. The traditional teaching of a BhCG level <1000 ruling out ectopic can distract from making the diagnosis of ruptured ectopic in a timely manner. Ectopic pregnancy may present with rising, falling or plateau, or even zero β -hCG levels.

 Ectopic Pregnancy: Ticking timebombs

You need to rule out ectopic pregnancy in ANY FEMALE OF REPRODUCTIVE AGE. We aren’t saying you need to do major workups, but if a female of reproductive age presents to the ED, have a very low suspicion for ordering a urine point of care pregnancy test.

 How to Handle Possible Ectopic Pregnancies in the Emergency Department

For patients presenting to the emergency department with complications of early pregnancy, the clinician’s primary goal is to localize the pregnancy, if possible, in order to minimize the risk of an undiagnosed ectopic pregnancy.

 Intern Ultrasound of the Month: Ectopic Pregnancy

Goal with POCUS: rule in IUP (GS + YS +/- FP) . If unable to confirm, it’s an ectopic until proven otherwise!

Articles of Interest

Case of the Month — Ectopic Pregnancy

Using the TAUS technique, an IUP is likely to be visualized starting after 6-7 weeks, whereas and IUP may be identified earlier on in gestation using the TVUS approach.

Ticking Time Bomb: Defusing Ectopic Pregnancy

Ectopic pregnancies can present in a variety of ways. Symptoms typically develop around 6-8 weeks after the last menstrual period. Women may misinterpret their vaginal bleeding as “normal menses”. Typical symptoms of pregnancy (breast tenderness, polyuria, nausea/vomiting) can also occur but with lesser frequency than IUPs, as the levels of human chorionic gonadotropin (hCG) are often lower.

Resources

CoreEM

Always consider the diagnosis of an ectopic pregnancy in any woman of child bearing age presenting with abdominal pain, vaginal bleeding, and missed period.

emDOCs

Ectopic pregnancy is a difficult diagnosis to make... In regards to the use of serum β-hCG levels in determining risk of ectopic pregnancy, ACEP indicates that, based on class II studies or strong class III studies, that the β-hCG value should not be used to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound.

LFTL

if bHCG is > 1200 and there is no intrauterine pregnancy = probable ectopic.

SAEM

Stable patients with EP may be managed medically with methotrexate. Medical management may preserve future fertility better than surgery. This agent interferes with DNA synthesis and replication of fetal cells, resulting in involution of the pregnancy. 36% of patients fail single dose therapy and require a second dose if β-hCG levels are not declining as expected.