 Welcome to emergency medicine video. In this video, we will discuss ectopic pregnancy. We will focus on the diagnosis and treatment in the emergency department. Ectopic pregnancy refers to any pregnancy that is implanted outside the uterus. Most of these will be in the fallopian tubes. As you can see, there is limited space in the fallopian tube. As the pregnancy keeps growing, at some point, it ruptures. The patient then bleeds into the pelvis and can quickly lose a lot of blood. Because of that, ectopic pregnancy is a cannot miss diagnosis in the emergency department. Who should we worry about ectopic pregnancy? There are a few risk factors that we might be able to gain from history. As a general rule, anything that disrupts the transport of the egg into the uterus will increase the risk of it being fertilized in the tube. Therefore, the risk factor includes any scarring of the tube from surgery, a previous pelvic inflammatory disease and a previous ectopic pregnancy with or without surgery, use of an internal uterine device. Even though the patient is less likely to get pregnant, if they get pregnant, the chance of an ectopic pregnancy is much higher. And patients on fertility treatment, just because they're more likely to have multiple fertilized eggs at the same time. Those are the questions you want to elicit on history. Keep in mind that even patients without risk factor can also have ectopic pregnancy. Let's move on to presentation. In the classic presentation, patients should be in the first stages of pregnancy. They should present with one-sided abdominal pain that's usually in the lower area. They might present with some vaginal bleeding. If they have ruptured due to the blood loss of the pelvis, they might also present with syncope. If the patient presents with these four presentations, you really want to think that the patient has a ruptured ectopic pregnancy. However, some patients can be tricky. As you know, patients don't often present in a classic way. This is how they might differ from the textbook description. First, early stages of pregnancy. Often patients may not know that they're pregnant. The fact that their menses was or is on time does not rule out an early pregnancy. You definitely want to do a pregnancy test to confirm. What about abdominal pain? While patients sometimes have pain with an ectopic pregnancy, not everyone have pain, especially if they're not ruptured. Also, not everybody's pain is localized to one side. It might be mid-light, and it might be mild or moderate, not severe. Even on physical examination, the tenderness might be mild as well. What about syncope? As you can imagine, patients may not have a syncopal episode if the ectopic has not ruptured. Syncope is a very late finding that suggests massive blood loss. Therefore, you do not want to wait for this. To summarize what we have so far, in history, we're going to ask about the risk factors in previous obstetric and gynecological history. In terms of physical, we want to do a physical and a pelvic exam to rule out other pathology, such as any GI causes for pain, GU causes including renal colic, pilonophritis, UTI, or a simple appendicitis. Next, we'll move on to investigations. As you can imagine, one of the first tests we like to know is whether the patient is pregnant or not. Any women of child-bearing age with any abdominal pain or vaginal bleeding or a syncope needs to have a pregnancy test done. The fastest way to do this is a urine-beta-HCG test. The urine-beta-HCG should be positive 8-10 days after conception, unless the urine is very diluted. If this is positive, and we have a strong suspicion of an ectopic pregnancy, particularly if she is hypotensive, we need to move her quickly into a monitor area and start resuscitation. We'll want to hook her up to the cardiac monitor and start two large variety. If she is hypotensive, 1-2 liters of saline will be given and we keep checking her vital signs. If it does not normalize, blood might be needed. Once we start to stabilize the hypotensive and stable patient, we can start to do other blood work. That includes a quantitative serum-HCG test that will give you the number of the HCG level, a CPC to check for hemoglobin, and a type in screen to find out the patient's blood type. What about diagnosis? We first use a bedside ultrasound to help us. On the bedside ultrasound, the first thing we look for is free fluid in the abdomen. If there is free fluid in the abdomen, that means the ectopic pregnancy has ruptured, and we're now seeing the blood that's freely flowing in the abdomen. We need to call the specialist right away. In this ultrasound image, you can see the free fluid in Morrison's pouch between the liver and the kidney. What about if you still have a hypotensive patient but the ultrasound does not show free fluid? If your index of suspicion is high, we will still call the obstetrician right away because sometimes the ultrasound might be falsely negative if there is not a lot of free fluid collected yet. Just to recap, if there is a patient in her first trimester pregnancy that you're worrying about, an ectopic, either the presence of free fluid on an ultrasound or an unstable patient should prompt a phone call to the consultant. In other words, unstable patient, contact consultant, stable patient with free fluid on the bedside ultrasound, also contact consultant. What about the stable patient who has no free fluid on the bedside ultrasound? Our question now becomes, is there an interuterine pregnancy on the ultrasound? It can either be done at the bedside by qualified physicians or in the radiology department. Based on the results of this ultrasound, there can be two outcomes. Either there is yes, there is an interuterine pregnancy, or no interuterine pregnancy is seen. Let's go through those. In this patient, we can see an interuterine pregnancy in the uterus. In a patient who is not undergoing fertility treatment, the presence of an interuterine pregnancy significantly decrease the risk of ectopic pregnancy. In patients with fertility treatment, because there could be multiple gestations that are formed, the presence of an interuterine pregnancy does not rule out an ectopic pregnancy. In a patient who is not undergoing fertility treatment, the presence of this interuterine pregnancy is very reassuring to us. If the patients remain stable, they can likely go home and follow up with their own doctor. What about in the patient who is stable, who does not have free fluid on the bedside ultrasound? However, on focus screening, there is no interuterine pregnancy that is seen. What does that mean? It can mean still that there is a non-rupture ectopic pregnancy because the patient is stable and there is no free fluid in the bedside ultrasound. Or this is simply a very early interuterine pregnancy that we're just too early to pick up on the ultrasound. How do we sort that out? We're going to use the quantitative beta that we get from the serum to help us. A transvaginal ultrasound should be able to pick up an interuterine pregnancy if the beta HCG is over 2,000. So if the beta HCG in this patient is more than 2,000 and you have not been able to see an interuterine pregnancy on transvaginal ultrasound, we have to assume that the pregnancy is somewhere else and therefore we're worried about ectopic. Often what we do is we have the ultrasoundographer try to sweep in the anexa to see if they see something that is suggestive of an ectopic pregnancy, so masses in the anexa. What if it's less than 2,000 and we don't see any interuterine pregnancy because we don't expect to see it? Now if there is any worrisome things on the ultrasound like an exo masses, we will still be worried about an ectopic. However, if we don't see anything at all, the patient doesn't have free fluid, they are stable, their beta is less than 2,000 and we can't see anything at all in the ultrasound, they can still be a very early interuterine pregnancy or an ectopic. These are very tricky patients and we tend to discuss with a consultant about what we would do. If they're stable, we often bring them back and repeat both the beta HCG and the ultrasound until an interuterine pregnancy can be ruled in. Clearly, if they have worsening signs of symptoms or a syncope, they need to come right back. Just to recap, unstable patient or stable patient with positive free fluid on the ultrasound needs to be referred right away. In the patient who is stable, who have no free fluid, a positive interuterine pregnancy on the ultrasound in a patient who is not undergoing fertility treatment makes the risk of ectopic extremely low. Those are the patients we can likely send home. In the patient without an interuterine pregnancy, if their beta HCG is more than 2,000 or if you see an ennexal abnormality, then you're worried about an ectopic pregnancy. Again, the consultant needs to be reached. In those whose beta HCG is less than 2,000 with no abnormality seen on the ennexa, they need to be reassessed frequently. Let's talk a little bit about treatment. What happens after we diagnose an ectopic pregnancy? As you can imagine, any unstable patient will need to go to the operating room. For stable patients, the treatment is a joint decision between the consultant and the patient. For small ectopic pregnancy that has not ruptured, the consultant might give medicine to stop the pregnancy from growing and to let it abort on its own. Let medicine is methotrexate. This medicine has a 30% failure rate and sometimes the dose needs to be repeated. Therefore, if a patient with a diagnosed small ectopic pregnancy, even if they're on methotrexate, they have a chance that the medicine have failed and the pregnancy keep growing and then they can show up with a ruptured topic with unstable vital signs. These patients often get very close follow-up and know what signs and symptoms return. Depending on the center you work, a dose of Robam is also given to patients who are in RH negative on the type N screen. To recap, all females of child-bearing age needs a urinbrata HCG. Patients who have no risk factor can still have an ectopic pregnancy. Any patients who are unstable or have free fluid in the abdomen needs to go to the operating room. For stable patients, the management is a combination of what shows up on the ultrasound in terms of whether there is or not an intrauterine pregnancy and how high the beta HCG level is in the blood. An ectopic pregnancy because of the potential devastating complication is a must-not-miss diagnosis in the emergency department. We hope you enjoy it. Thank you very much for watching.