6. CONDITION: Presumed Ectopic Pregnancy in a clinically stable patient
A. Confirmation of Diagnosis:
(1) Documented history consistent with the diagnosis of ectopic pregnancy, including any of the following:
(a) Pelvic pain;
(b) Abnormal uterine bleeding;
(c) Risk factors such as previous ectopic, PID, tubal surgery, or IUD usage;
(d) Characteristic menstrual history.
(2) Documented physical findings consistent with the diagnosis ectopic pregnancy, including any of the following:
(a) Pelvic tenderness;
(b) Pelvic mass;
(c) Uterine characteristics consistent with pregnancy.
(3) Documented laboratory findings consistent with the diagnosis of ectopic pregnancy, including any of the following:
(a) Positive pregnancy test;
(b) Ultrasound findings consistent with pregnancy test results.
B. Management of a Clinically Stable Patient:
(1) Ultrasound
(a) Assume an intrauterine pregnancy if a fetal sack is visualized in the uterine cavity;
(b) If no fetal sack is visualized then:
(1) Obtain a baseline quantitative serum bHCG;
(2) Advise patient of warning signs of ectopic pregnancy;
(3) Repeat bHCG every 48-72 hours looking for doubling;
(a) If value doubles every 48 hours, repeat ultrasound until an IUP is confirmed;
(b) If doubling does not occur, ectopic or nonviable IUP should be suspected and management depends on the clinical and laboratory evaluations:
(i) Consult and/or referral to a specialist should be considered;
(ii) Recommend serial studies until diagnosis is confirmed;
(iii) Falling bHCG levels can be successfully followed without surgical intervention, provided the patient remains hemodynamically stable and has no other findings that prompt surgical intervention;
(vi) Consider hospital vs outpatient observation.
(2) Document consideration of laparoscopy or laparotomy if intrauterine pregnancy is unlikely based on this evaluation.
(3) Laparoscopy or laparotomy is indicated with any of the following:
(a) Increasing symptoms;
(b) Developing mass;
(c) Suggestive ultrasound;
(d) high index of suspicion.
(4) Follow-up care
(a) bHCG should be monitored weekly until serum level is negative (should occur within 8 weeks);
(b) Low dose prophylaxis, (Microgram), should be considered in an Rh-patient.
(References: Precis IV: An Update in Obstetrics and Gynecology, Gynecology Section, Medical Specialty Advisory Committee, Maine Demonstration Project)
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