Diagnosing the Extrauterine Pregnancy-What You Need to Know
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Outline the frequency of repetitive quantitative HCG (qHCG) measurement and when it is necessary 2. Identify the discrimatory zone of qHCG and why it is important
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
The goal of diagnosing an ectopic pregnancy is to make the determination before rupture, allowing conservative, medical treatment
Transvaginal Ultrasound (TVU)
If TVU definitively shows ectopic pregnancy (gestational sac with yolk sac and/or embryo in adnexa), or failed intrauterine pregnancy, treat accordingly
Mass or hypoechoic area separate from the ovary is ‘suspicious’ but not diagnostic
PPV is only 80% and may be confused with paratubal cyst, corpus luteum, hydrosalpinx, endometrioma or bowel
If TVU is not diagnostic, quantitative hCG becomes helpful
Quantitative hCG (qHCG)
Absence of gestational sac in the uterus above ‘discriminatory level’ has a PPV of 50 to 70%
If this concept used, set qHCG level high, e.g. 3,500 mIU/mL
Multiple gestation may have higher qHCG levels (>2,000 mIU/mL) before ultrasound evidence of pregnancy is visible
Trending hCG levels
If TVU is nondiagnostic and fails to show a gestational sac with yolk sac in the uterus (normally visible between 5 and 6 weeks gestation) or the adnexa
Measure qHCG and then repeat in 48 hours
Repeat again every 2 to 7 days based on level/pattern of qHCG results
Higher the initial level, slower the expected rate of increase
<1,500 mIU/mL – 49% increase rate
1,500-3,000 mIU/mL – 40% increase rate
>3,000 mIU/mL – 33% increase rate
An increase in qHCG of less than 50% in 48 hours in an early pregnancy is very concerning but cannot determine location, i.e., ectopic vs intrauterine
1% of patients with early viable pregnancies may not meet minimal increase thresholds in 48 hours
NOTE: Obtain blood type and Rh status on all women suspected of ectopic pregnancy and all Rh-negative women with bleeding should receive RhO(D) immune globulin (RhoGam), regardless of the final outcome of the pregnancy
Over 90% of ectopic pregnancies are in the fallopian tube; the remainder can occur in the cervix, ovary, uterine cornua or abdomen. Risk factors for ectopic pregnancies include tubal surgery, PID, previous ectopic pregnancy (10% with one previous ectopic rising to 25% with ≥2), infertility, assisted reproductive technologies with multiple embryo transfer, previous pelvic/abdominal surgery, age >35 years and smoking. IUDs are associated with fewer ectopics compared to women not using contraception because IUDs are such an effective method of birth control. However, if a woman does become pregnant with an IUD, the risk of an ectopic is approximately 50%. Note that at least half of women with ectopic pregnancies have no risk factors.
Have a high index of suspicion for ectopic pregnancy in any premenopausal woman with abnormal uterine bleeding and pain
Aside from history and clinical examination, qHCG and TVU are critical for appropriate diagnosis
If the patient is pregnant, the TVU is equivocal and the patient is clinically stable, follow with serial qHCGs
Patient must be able and willing to return for labs and follow-up ultrasounds
The discriminatory zone, in practice, is still dependent on multiple factors, including the quality of the ultrasound machine, the skill of the sonographer, and the presence/absence of multiple gestations
If TVU or qHCG is not available, or if the clinical picture remains unclear, diagnostic endometrial aspiration to confirm chorionic villi may be necessary
Patients should be counseled in advance that this will terminate the pregnancy if intrauterine
>15% decrease decrease in qHCG levels between 12 and 24 hours following aspiration suggests that villi have been removed
Continue monitoring qHCG until negative and if plateau or increase, consider nonvisualized ectopic pregnancy, especially if villi do not appear in the specimen
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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