This patient is a 30-year-old female who presented with vaginal spotting during her first trimester of pregnancy. An ultrasound was ordered which did not show an intrauterine or ectopic pregnancy. The patient's beta-hCG level was measured at 1056. At follow-up two days later, the patient's symptoms had resolved but her beta-hCG had risen to 1465. A repeat ultrasound now showed a right tubal ectopic pregnancy, so the patient underwent a laparoscopic right salpingectomy to remove the ectopic pregnancy from her fallopian tube.

1. CASE
This patient is a 30 year old F who is coming in for:
#Vaginal Spotting
= Patient was seen by her PCP and confirmed to be pregnant and referred out
to see a OBGYN due to a history of cancer in her left arm (synovial carcinoma).
LMP: 6 weeks ago
= Pt came to clinic complaining of some spotting, brownish, has some pelvic
pain and lower back pain that was intermittent, rate 3-4/10
= No urinary frequency, dysuria currently, no fevers, chills, nausea or vomiting.
= Had one previous pregnancy and did not have issues during that pregnancy.
= Speculum exam does not yield any findings of miscarriage and no lesion seen
to explain bleeding.

3. A/P
# Vaginal spotting during 1st trimester pregnancy
= STAT transvaginal US for r/o miscarriage versus ectopic.
= Qnt beta HCG stat sent to lab.
=F/u in Super clinic in 48 hours

4. ……..48hrs later -
• Pt presents to follow up appointment.
• Denies vaginal spotting, no cramps, no abdominal pain, no
vomiting, no fever, no urinary symptoms.
= U/s shows: no intrauterine pregnancy, no ectopic pregnancy.
= Qnt beta HCG : 1056

5. Gloria Monsalve M.D.

6. “Any pregnancy where the fertilised ovum gets implanted &
develops in a site other than normal uterine cavity”.
First-trimester bleeding or abdominal pain  consider ectopic
pregnancy as a possible cause.

9. Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-
control, population-based study in France. Am J Epidemiol. 2003;157(3):185–194.

10. Prior history of PID

11. Diagnosis
• The most common symptoms of an unruptured ectopic
pregnancy are first-trimester bleeding and abdominal pain.
• Pregnancy dating.
• Risk factors for ectopic pregnancy.
• Severity of symptoms hemodynamic.

12. PHYSICAL EXAMINATION
• Peritoneal signs.
• Hemoperitoneum.
• Inspection of the cervical os for bleeding and evidence of products of
conception.

13. When a woman presents with an early
pregnancy + symptoms
• Ask yourself two questions…
Where is this pregnancy?
Is it viable?

14. IMAGING
• Transvaginal ultrasonography.
• By 6 weeks' gestation, an intrauterine pregnancy should be identifiable.
• If TV us visualizes a gestational sac or embryonic pole in an ectopic
location, treatment for the ectopic pregnancy should be initiated.
The diagnostic challenge occurs when ultrasonography
does not identify a pregnancy as intrauterine!!
Levine D. Ectopic pregnancy. Radiology. 2007;245(2):385–397.

15. Transvaginal ultrasound ( TVS):

16. β-hCG discriminatory value (or zone)
• It is the lower limit of hCG at which an examiner can
reliably visualize pregnancy on ultrasound.
• It is 1,500 to 2,000 IU/L with vaginal ultrasound and
5000-6000 IU/L with abdominal ultrasound.

17. Doubling sign:
• Most viable first-trimester intrauterine pregnancies (99%) have β-hCG
values that increase by about 50% -66% in 48 hours.
Failure to increase at this rate suggests an
ectopic pregnancy or a nonviable intrauterine
pregnancy.

18. Blood Type and Rh Status.
• A blood type and screen should be obtained on all women with
suspected ectopic pregnancy to determine Rh status.
• Women with Rh-negative results who experience bleeding should
receive RhO(D) immune globulin (RhoGam), regardless of the final
outcome of the pregnancy, to protect against development of Rh
alloimmunization

19. LAPAROSCOPY
• If the diagnosis is still uncertain, diagnostic laparoscopy should be
considered.

21. Treatment
1. Methotrexate therapy
2. Open or laparoscopic surgery
3. Expectant management.
For patients who are medically unstable or
experiencing life-threatening hemorrhage, immediate
surgical treatment is indicated.

22. Laparoscopic salpingostomy vs medical
treatment
• A 2007 Cochrane review found no difference in success rates between
laparoscopic salpingostomy and medical treatment with
methotrexate, as well as no differences in tubal patency and
subsequent fertility rates.

23. MEDICAL TREATMENT
• Patient selection is important in the medical management of ectopic pregnancy.
• The lower the beta-hCG levels at initiation of treatment, the higher the success
rate of methotrexate therapy

24. Contraindications to Methotrexate Therapy for Ectopic Pregnancy

25. Regimens.
Single-dose regimen is preferred because it has a lower rate of
adverse effects, does not require folic acid rescue, involves less
frequent monitoring, and is cost-effective.
Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F. Interventions for tubal ectopic
pregnancy. Cochrane Database Syst Rev. 2007;(1):CD000324.

26. Follow-up.
• β-hCG level should decrease by at least 15% from day 4 to day 7 after
injection.
• However, could be a plateau or increase before it begins to decrease.
• After the 15% decrease occurs, β-hCG levels should be monitored weekly
until they reach zero. (5-7 weeks)
• If the β-hCG level does not decrease by at least 15 % additional
methotrexate administration or surgical intervention is required.

27. EXPECTANT MANAGEMENT
• Patients with low and decreasing β-hCG levels, no evidence of an
ectopic mass visualized by transvaginal ultrasonography, and minimal
symptoms
• Expectant management is between 47 and 82 percent effective in
managing ectopic pregnancy.

28. Surgical management:
Surgical options include salpingectomy or salpingostomy.
Performed by laparoscopy or laparotomy.
Laparotomy is reserved for patients with extensive intraperitoneal
bleeding, intravascular compromise, or poor visualization of the
pelvis at the time of laparoscopy

29.  Salpingostomy / Salpingotomy is only indicated
when:
1. The patient desires to conserve her fertility
2. Patient is haemodynamically stable
3. Tubal pregnancy is accessible
4. Unruptured and < 4Cm. In size
5. Contralateral tube is absent
or damaged

30. Returning to our patient
• Qnt beta HCG: 1056 on-->1465
• TV US

31. OPERATION:LAPAROSCOPIC RIGHT
SALPINGECTOMY.

32. FUTURE FERTILITY AND RISK OF RECURRENCE
• Approx 30 percent of women treated for ectopic pregnancy later have
difficulty conceiving.
• Recurrent ectopic pregnancy are between 5 - 20 %
• Risk increases >30% in women who have had two consecutive ectopic
pregnancies