208 PART II: PRIMARY CARE DISORDERS
Management
When a nonviable pregnancy has been diagnosed, the
patient should be counseled as toher two mainoptions,
one of whichis tosimply wait and see ifa spontaneous
abortion willoccurintheensuing2–4weeks.Theother
choiceisforhertoelecttohaveheruterusevacuatedby
meansofauterinedilatationandcurettage(D&C).AD&C
under these circumstances can be done as an outpatient
procedureunderlocalorlightgeneralanesthesiawithmini
malriskofsignicantbloodlossorothercomplications.
TwosituationswhereaD&Cmayberequiredtocon
clude a nonviable pregnancy are missed abortions and
incomplete abortions. In the former, the uterus fails to
initiatesufcientcontractionstotriggerthespontaneous
abortion and thereby expel the pregnancy. Nonejected
productsofconceptionwilleventuallyformapermanent
polyplikeresiduethatmaypartiallycalcify.Theresulting
intrauterine mass may cause abnormal uterine bleeding
andpreventfuturepregnanciesinamannersimilartoan
intrauterinecontraceptivedevice. Therefore,ifasponta
neousabortionhasnotoccurredby14weeksofgestation
orby6weeksafterthediagnosisofanonviablepregnancy,
aD&Cisindicated.Infact,manywomennditdifcult
psychologically to continue to carry a nonviable preg
nancyandoftenelecttoundergoaD&Crelativelysoon
afterthediagnosisismade.
Inthecaseofanincompletespontaneousabortion,the
uterinecrampingejectsonlypartoftheproductsofcon
ception.Inthesesituationsthewomanoftenexperiences
prolongedandseverecrampingandheavyvaginalbleed
ingandusuallypresentstotheemergencydepartment.A
D&C will quickly stop the cramping and dramatically
reduce the amount of bleeding. The blood loss with
incomplete spontaneous abortions can be sufcient to
requirebloodtransfusion.
Incomplete abortions are uncommon with early preg
nancylosses(5–7weeks)butmayoccurinasmanyas10
to15percentoflatersttrimesterlosses.Ifawomanwho
appearstohavesuccessfullycompletedaspontaneousabor
tionresumescrampingandbleedingdaystoafewweeks
later, an incomplete abortion may also be suspected and
thenconrmedbytransvaginalultrasound,whichcanvisu
alizeretainedproductsofconception.AD&Cisalsoindi
catedinthissituation,bothtoendthebleedingandcramping
andtopreventauterineinfection(septicabortion),which
canbelifethreateningifnottreatedproperly.
Lifestyle Changes: Practical Tips for Your
Patients
Afteraspontaneousabortionhasoccurred,thewoman
andherpartnerrequireappropriatecounselingandsup
port from their medical care providers. A miscarriage
seems like a trivial eventonly to thosewhohavenot
experiencedone.Thosewhohavewilltestifytothehigh
levelsofgrief,anger,andguiltthelossengenders.Itis
importanttopointouttothecouplethatthelosswas
theresultofanyerrorsofomissionorcommissionon
theirpart.Ratheritwasaneventthatwasbeyondtheir
abilitytocontrolbecausetheultimateproblemwassim
plythattheembryowasnotintrinsicallyhealthyenough
to survive even in an optimal uterine environment.
Theoccurrenceofonespontaneousabortionwillnot
inuencethechancesofsuccessforthenextpregnancy.
Nonetheless, anxiety levels will be higher during the
subsequent pregnancy, and many clinicians will offer
suchcouplestheoptionofserialultrasoundexamina
tions every 7–10 days during the rst trimester from
7–10weeks.Anultrasoundat10weeksofgestationthat
demonstratesnormalndings(includinganormalsize
fetuswithspontaneousmovementsandnormalcardiac
activity) indicates an approximate 98 percent chance
thatthepregnancywillresultinthelivebirthofanor
mal infant. Couples experiencing two consecutive
spontaneousabortionswillhaveaslightlyhigherthan
normalchanceformiscarriageinthethirdpregnancy,
forreasonsthatremainunclear.Coupleswithahistory
of threespontaneousabortionsandno livebirths are
best referred for a series of tests to detect correctable
causesofrecurrentabortion.Suchtestingoftenincludes
chromosomalanalysisofbothpartners(toexcludebal
anced chromosomal translocations), ultrasound or
radiographic contraststudiesofthe uterus,hormonal
tests(toevaluateforthyroiddiseaseandoocytereserve),
andpossiblyteststoexcludeimmunedysfunction.
5
Ectopic Pregnancy
General Characteristics
Inapproximately1outofevery200pregnancies,thecon
ceptionimplantsinalocationotherthantheendometrial
lininginthefundusoftheuterus.Themostcommonsite
by far for these ectopic gestations is the fallopian tube,
particularlytheportioncomprisingthedistaltwothirds,
which is the ampullary segment. Fully 95percent of all
ectopicsarefoundinthefallopiantube,withtheremain
deroccurringintheovary,cervix,andabdominalcavity.
Pregnanciesthat implant in ectopic locations eventu
ally expand until they are capable of causing pain and
lifethreateninghemorrhageatsomepointinthersttri
mester.Prior tothe 20th century, approximately70 per
centofectopicpregnanciesprovedfataltoboththemother
and the pregnancy. Today ectopic pregnancies remain a
majorcauseofmaternalmortality,eventhoughthedeath
ratehas declinedto 1to 3 percentin the United States.
Prior to 1980, the vast majority of ectopic pregnancies
werenotdiagnoseduntilafterruptureofthesiteofimplan
tation(usuallythefallopiantube)andthuspresentedas
lifethreateningemergencies thatrequiredblood transfu
sion and immediate surgery. Because of the widespread
availability of sensitive assays of HCG and ultrasound,
mostectopicstodayarediagnosedpriortorupture.
Anumberoffactorshavebeenshowntoincreasethe
riskofectopicpregnancy,includingpriortubalinfections
(salpingitis), previous tubal surgery, prior ectopic preg
nancies,cigarettesmoking,andconceivingwithanintra
uterinedeviceinplace.Becauseafertilizedoocytenormally
Chapter 16: Obstetrics and Gynecology 209
spends3daysintransitdownthefallopiantube,themain
conceptofriskisthatdamagetothetubalmucosadelays
embryo transport sufciently to increase the chance of
ectopicimplantation.
Nonetheless,inapproximatelyhalfofectopicpregnan
ciestherewillbenoidentiableriskfactorsandnodamage
evidenttothefallopiantubesorotherpelvicorgans.From
thisobservationithasbeenconcludedthattheremaybe
undiscoveredriskfactorsand/orthatectopicimplantation
cansometimesoccurpurelyasaresultofchance.
Signs, Symptoms, and Diagnosis
Thetwomostcommonsymptomsforectopicpregnancyare
pelvicpainandvaginalbleedinginthersttrimester.The
painmayinitiallybecramplikeincharacterandnotlocalize
tothesiteofectopicimplantation.Thusearlyinpregnancy
(6–8weeks)itmaybedifculttodistinguishapatientwith
anectopicfromonewithanimpendingspontaneousabor
tion. Eventually,however, thepain becomes moresevere,
moresharpincharacter(knifelike),andlocalized.
Thetwomostusefuldiagnostictestsincasessuspicious
for ectopic pregnancy are transvaginal ultrasound and a
serumquantitativeassayofHCG.Withultrasoundtherst
ndingofimportanceistheabsenceofanintrauterinegesta
tion,especiallyiftheHCGlevelisfoundtobegreaterthan
thethreshold(typically1500–2000mIU/mL)whereanintra
uterinepregnancyisnormallyvisible.Inabout15percentof
ectopicpregnancies,ultrasoundwillbeevenmorepreciseby
visualizingagestationalsaccontainingaviableembryothat
isclearlyoutsidetheuterus.Intheremainderofcaseswhere
thereisnotaviableembryoandthegestationalsacispoorly
developed,ultrasoundisstillusuallyabletodetecta2–5cm
amorphousmassononesideofthepelvis,whichrepresents
theectopic.Iftherehasbeenanysignicantintraabdominal
bleedingfromtheectopicmass,ultrasoundwilldetectthis
asfreeuidinthepelvicculdesac.
Management
In the typical case, pain and bleeding lead to an ultra
soundat6–8weeksofgestation,whichshowsanempty
uterinecavityandanamorphousmassintheareaofone
fallopian tube. Combined with an HCG level elevated
abovetheintrauterinepregnancydetectionthreshold,this
issufcienttodiagnoseanunrupturedectopicpregnancy.
Themaintreatmentoptionsforthepatienttoconsiderat
thispoint arelaparoscopicsurgeryormedical treatment
withmethotrexate(MTX).
Laparoscopicsurgeryhastheadvantagesofmoreimme
diateresolutionoftheectopicanddirectvisualizationofthe
pelvicorgans,whichcandemonstratetubaldamagecaused
bypriorinfection,ifpresent.Theusualmethodforthelap
aroscopicremovaloftubalectopicpregnanciesissalpingos
tomywhereasmalllinearincisionismadeoverthebulging
segment of the fallopian tube that contains the ectopic.
Throughthisopeningtheproductsofconceptioncanthen
becarefullyextracted.Thechancesthattheaffectedtubewill
healsufcientlywelltofunctionnormallyinthefutureare
reasonablygood (75 to 85 percent).As with most laparo
scopicprocedures,thepatientmaybedischarged4–6hours
later.OneortwofollowupquantitativeHCGbloodtestsat
weeklyintervalsarewarrantedtoensurethatalltrophoblas
ticcellsfromthepregnancywereinfactremoved.
MedicaltreatmentwithMTXhas the mainadvantage
ofavoidingthesmallbutdeniterisksofgeneralanesthe
sia and laparoscopic surgery. MTX is a cytotoxic and
immunosuppressivedrugthathasbeenavailableformore
than50yearsandisutilizedfrequentlyinthetreatment
ofcertaincancersandautoimmunedisorders.Pregnancy
cells(trophoblasts)aresosensitivetoMTXthatasingle
intramuscularinjection of thedrugis often sufcientto
causethegradualreabsorptionofanunrupturedectopic
pregnancy.
Patients who choose MTX treatment must be followed
carefullyaftertheinitialinjectionofthedrug.FrequentHCG
assaysarerequired tomakesuretheectopic is responding
appropriately.GenerallytheHCGlevelsshouldbedeclining
within5daysaftertheMTXinjectionandwillreachunde
tectablelevelsin6–12weeks. Inapproximately20percent
ofcases,aseconddoseofMTXisnecessary1–2weeksafter
therst.MTXisgenerallysuccessfulinresolvingectopicsin
90percentofcases.Intheremaining10percent,tubalrup
ture occurs or the patient experiences excessive pain and
requires laparoscopy. Patients with initial HCG levels of
15,000mIU/mLorhigherandthosewithviableembryosin
theirectopicgestationalsacsaregenerallyconsideredtobe
poor candidates for MTX because of a lowered chance of
success(50to60percent)andbecausetheyoftenexperience
considerablepainduringtheresolutionprocess.
Onespecialcircumstancethatsometimesoccursiswhen
acouplewithpreviousinfertilityconceivesanectopicpreg
nancy.Inthissituation,laparoscopyisthepreferredmethod
ofremovingtheectopicbecauseoftheadditionaldiagnostic
informationitcanprovideregardingtheoverallhealthofthe
fallopiantubes.Also,iftheembryoappearsviableonultra
sound(asitdoesin15percentofcases)thecouplemayask
ifthepregnancycansomehowbesavedbyasurgicalproce
duretorelocatethegestationalsacfromthefallopiantubeto
theuterus.Unfortunatelytheymustbetoldthatsuchapro
cedureiscurrentlyimpossiblebecauseofthediversenature
ofthebloodsupplytotheplacentaandtheissueofcreating
a large enough opening in the uterine wall to permit the
transferwithoutcausingapermanentweaknessthatwould
leadtocatastrophicuterinerupturelaterinthepregnancy.
Lifestyle Changes: Practical Tips for Your
Patients
After resolution by either MTX or surgery, patients
withectopicpregnanciesmustbecounseledregarding
their increased risk of another ectopic in their next
pregnancy.Studiesevaluatingthisissuehavereported
riskratesof15to25percentforarepeatectopic.Thus
thesepatientswillgreatlybenetfromtheearlydiag
nosisofthenextpregnancyfollowedbyanearlyultra
sound evaluation. Ultrasound is capable of demon
stratinganormalintrauterinepregnancyby6weeks
ofgestation,andingthatwillprovideconsiderable
reliefofanxietyforacouplewithahistoryofaprevi
ousectopicpregnancy.

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