Ectopic Pregnancy

Ectopic pregnancy refers to the implantation of a fertilized egg (embryo) outside the uterine cavity. The main cause is disruption of the normal anatomy of the fallopian tube. Consequently, affected patients may suffer from acute abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain as the developing embryo increases in size. Ectopic pregnancy can be quickly diagnosed by means of an ultrasound and laboratory analysis. Management can be expectant, medical, or surgical. Severe cases involving rupture of the fallopian tube and hemorrhage are considered a medical emergency and require immediate surgery.

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Epidemiology and Etiology

Epidemiology

  • 3rd-leading cause of maternal mortality 
  • 1%–2% of all pregnancies
  • Diagnosed in approximately 10% of patients presenting with vaginal bleeding and abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in early pregnancy

Etiology

Ectopic pregnancy (EP) can occur when the fertilized egg does not enter the uterine cavity by way of the fallopian tube by the 5th to 6th day of gestation. 

  • Caused by:
    • Disorders of the ovulation mechanism (e.g., as seen in polycystic ovarian syndrome Polycystic ovarian syndrome Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome ( PCOS PCOS Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome))
    • Blockage of the embryo’s tubal passage: Tubal passage may be affected by congenital anomalies, acquired tubal obstructions, and disruption of ciliary activity or tube motility.
  • Risk factors:
    • Pelvic inflammatory disease Pelvic inflammatory disease Pelvic inflammatory disease (PID) is defined as a polymicrobial infection of the upper female reproductive system. The disease can affect the uterus, fallopian tubes, ovaries, and adjacent structures. Pelvic inflammatory disease is closely linked with sexually transmitted diseases, most commonly caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Gardnerella vaginalis. Pelvic Inflammatory Disease (50% of cases, increases risk 3-fold) 
    • Adhesions after tubal surgery (25% of cases)
    • Assisted reproduction (e.g., in vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week ( IVF IVF Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids))
    • Prior EP or abortion
    • Abnormal endometrium (e.g., endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis or fibroids)
    • Congenital malformation of the uterus (bicornuate uterus)
    • Smoking
    • Advanced age (> 35 years old)
    • Intrauterine device/oral contraceptives (if pregnancy occurs despite their use)
  • Potential locations of implantation: 
    • 95% within the fallopian tube 
    • 3% in the ovary
    • 1% in the peritoneal cavity (abdominal)
    • < 1% in the cervix
Types of ectopic pregnancy

Different types of EP according to location

Image by Lecturio.

Clinical Presentation

  • May present as an acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen
    • Severe lower abdominal or pelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Pain may be more diffuse if there is blood in the abdominal cavity.
    • If pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain radiates toward the shoulder → sign of tubular rupture
  • Spotting or vaginal bleeding (may lead to hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock)
  • General pregnancy symptoms:
    • Breast enlargement and tenderness
    • Secondary amenorrhea Secondary Amenorrhea Secondary amenorrhea is defined as the absence of menses for 3 months in a woman with previously regular menstrual cycles or for 6 months in a woman with previously irregular cycles. Etiologies involve either disruptions to the hypothalamic-pituitary-ovarian (HPO) axis or acquired obstructions in the uterus or outflow tract. Secondary Amenorrhea 
    • Morning sickness

Diagnosis

History and clinical examination

  • Patients may report a missed or irregular last menstrual period
  • Abdomen: guarding upon palpation of the lower abdomen
  • Pelvis: 
    • Cervical motion tenderness (must differentiate from pelvic inflammatory disease (PID))
    • Closed cervix
    • Adnexal tenderness
    • An adnexal mass may be felt in 10%–20% of cases.
  • Vital signs: tachycardia and hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension in the case of a ruptured EP

Labs

  • Very important: Perform a pregnancy test on all women of reproductive age who present with abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Urine or serum beta human chorionic gonadotropin (HCG): Elevated level confirms pregnancy.
  • Type and screen: blood type and Rh factor (if negative, RhoGam is required)
  • Complete blood count (CBC): to look for anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview/evidence of hemorrhage
  • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests (LFTs), basic metabolic panel (BMP), urinalysis (UA): to evaluate for other causes of acute abdomen Acute Abdomen Acute abdomen, which is in many cases a surgical emergency, is the sudden onset of abdominal pain that may be caused by inflammation, infection, perforation, ischemia, or obstruction. The location of the pain, its characteristics, and associated symptoms (e.g., jaundice) are important tools that help narrow the differential diagnosis. Acute Abdomen

Diagnostic studies

  • Ultrasound:
    • Normal pregnancy: At 5–6 weeks’ gestation, a gestational sac and yolk sac are present within the uterus.
    • EP findings: 
      • An empty uterine cavity without an amniotic sac or with a pseudo-gestational sac
      • Enlargement of the fallopian tube with an amniotic sac
    • In the case of tubal rupture, free fluid (blood) is present in the pouch of Douglas.
    • Possible to determine if the embryo is alive by the detection of a fetal heartbeat
  • Diagnosis can be further confirmed by laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy (or pelviscopy). 

Management

An EP must be closely monitored. The management of an EP can be expectant, medical, or surgical depending on the patient’s condition.

Emergency management

  • Assess and stabilize ABCs (airway, breathing, circulation). 
  • Give intravenous fluids Intravenous Fluids Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids to compensate for blood loss.
  • Transfusion if blood loss is significant
  • If the patient has an Rh-negative blood type: Administer RhoGam to prevent Rh incompatibility in future pregnancies.

Medical management

  • Reserved for hemodynamically stable patients and those with a pregnancy sac < 3.5 cm and no fetal cardiac activity on ultrasound
  • Methotrexate (IV or locally applied) to induce a medical abortion
  • Must monitor the patient’s HCG levels to 0

Expectant management

  • Only for patients who meet the following criteria:
    • Asymptomatic
    • No evidence of extrauterine sac/mass on ultrasound
    • Low and decreasing serum HCG (≤ 200 mIU/mL)
    • Agreeable to close follow-up
  • Steps include: 
    • Monitoring the pattern of serial HCG levels (normal pregnancy: doubles approximately every 48 hrs; in EP, values will decline) 
    • Giving strict return-for-followup instructions to ensure that HCG is monitored
    • Abandoning expectant management if significant abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain develops or HCG increases or fails to decline

Differential Diagnosis

There are many differential diagnoses of an ectopic pregnancy. These diagnoses can be categorized into non-gynecological and gynecological causes.

Non-gynecological causes

  • Acute abdomen: severe, acute-onset abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that can be life-threatening and therefore requires urgent medical attention. Etiologies may be gastrointestinal (e.g., hepatitis), vascular, and/or genitourinary in nature. Diagnosis is often made using various radiographic studies. Depending on the severity of the condition, surgery may be required. Can be distinguished from EP by beta HCG and ultrasound (US).
  • Sigmoid diverticulitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the diverticula (outpouching of the mucosa due to weakness of the muscular layers of the colonic wall) of the sigmoid colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix. Erosion of the diverticular wall by thickened food particles can cause inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and lower abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Often diagnosed via computed tomography (CT) scan, on which colonic outpouchings and wall thickening can be seen. Treated with antibiotics and/or surgery in severe cases. 
  • Appendicitis Appendicitis Appendicitis is the acute inflammation of the vermiform appendix and the most common abdominal surgical emergency globally. The condition has a lifetime risk of 8%. Characteristic features include periumbilical abdominal pain that migrates to the right lower quadrant, fever, anorexia, nausea, and vomiting. Appendicitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the appendix caused by obstruction (e.g., by fecaliths or infection). Produces symptoms such as abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, vomiting, and malaise. Diagnostic findings may include an elevated WBC count and a thickened appendiceal wall on CT scan. Surgery is the recommended treatment, although some patients respond to antibiotics. Unlike in EP, US may reveal an enlarged appendiceal diameter.
  • Kidney stones: urine can become supersaturated with soluble substances (e.g., calcium oxalate), which crystallize and form stones that deposit throughout the urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract. Patients may present with colicky flank or abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. Diagnostic studies reveal hematuria, urinary stones on CT scan, and/or hydronephrosis Hydronephrosis Hydronephrosis is dilation of the renal collecting system as a result of the obstruction of urine outflow. Hydronephrosis can be unilateral or bilateral. Nephrolithiasis is the most common cause of hydronephrosis in young adults, while prostatic hyperplasia and neoplasm are seen in older patients. Hydronephrosis on US. Management consists of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control and varies depending on the chemical nature of the stones. 
  • Urinary tract infection ( UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections): infection of the urethra, bladder, or kidney most commonly caused by bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview. Often presents with frequent and painful urination, hematuria, lower abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever. Diagnosis is with UA showing leukocytes, blood, and nitrite, but no elevated HCG, which helps differentiate this condition from EP. Treatment is conservative, with increased fluid intake and, in severe cases, antibiotics.

Gynecological causes

  • PID: an infectious disease of the upper female reproductive tract (i.e., uterus, fallopian tubes, and/or ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries) along with its surrounding tissues. Sexually transmitted bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview are typically the cause, so mucopurulent discharge and a friable cervix may be present on exam. A negative pregnancy test can help distinguish this condition from EP. Antibiotic therapy tailored to the causative agent is the main treatment. 
  • Ovarian cyst rupture: fluid-filled sacs within an ovary or on its surface, which can form as a result of ovulation. If a cyst ruptures, it can cause severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and internal bleeding. Diagnostic findings may include an adnexal mass and free fluid within the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis on US, along with a negative pregnancy test. Management includes watchful waiting for uncomplicated cysts and surgery for those cysts associated with hemorrhage. 
  • Ovarian torsion Ovarian torsion Ovarian torsion is a clinical emergency in which the ovaries (with or without the fallopian tubes) twist along their axis, leading to partial or complete obstruction of their blood supply. Ovarian torsion is also called adnexal or tubo-ovarian torsion, especially if a fallopian tube is also involved. Ovarian Torsion: the complete or partial rotation of the ovary around its supporting ligaments. As a result, ischemic injury of the ovarian tissue occurs due to blood supply compromise. Associated with conditions that cause ovarian enlargement (e.g., cysts, tumors). May lead to acute abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and vomiting; US and pregnancy testing can be used to distinguish this condition from EP. Urgent surgical detorsion is indicated to preserve the ovary.
  • Polycystic ovarian syndrome ( PCOS PCOS Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome): a multisystem endocrinological disorder characterized by ovulatory dysfunction and hyperandrogenism. Patients may present with obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity and menstrual abnormalities. Rotterdam criteria (oligo- or anovulation, signs of hyperandrogenism, and polycystic ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries on US) are used to make the diagnosis. Unlike EP, PCOS PCOS Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder of reproductive-age women, affecting nearly 5%-10% of women in the age group. It is characterized by hyperandrogenism, chronic anovulation leading to oligomenorrhea (or amenorrhea), and metabolic dysfunction. Polycystic Ovarian Syndrome is associated with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility. Treatment depends on whether the patient is pursuing pregnancy.
  • Endometriosis: normal endometrial tissue is implanted outside the uterus, triggering an inflammatory response. Common symptoms include pelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, dysmenorrhea, and menorrhagia. Diagnosis is confirmed by post-surgical histologic evaluation of a biopsied lesion. Tends to be associated with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility and chronic dysmenorrhea, distinguishing the condition from EP. Management can be medical or surgical, depending on the severity of symptoms.
  • Endometrial hyperplasia Endometrial Hyperplasia Endometrial hyperplasia (EH) is the abnormal growth of the uterine endometrium. This abnormal growth may be due to estrogen stimulation or genetic mutations leading to uncontrolled proliferation. Endometrial Hyperplasia and Endometrial Cancer: abnormal proliferation of the uterine endometrium. Caused by excess estrogen being unopposed by progesterone, which then causes abnormal uterine bleeding Abnormal Uterine Bleeding Abnormal uterine bleeding is the medical term for abnormalities in the frequency, volume, duration, and regularity of the menstrual cycle. Abnormal uterine bleeding is classified using the acronym PALM-COEIN, with PALM representing the structural causes and COEIN indicating the non-structural causes. Abnormal Uterine Bleeding. The gold standard for diagnosis is endometrial sampling. Typically managed via surveillance, pharmacotherapy, or surgery. Although endometrial hyperplasia can cause abnormal bleeding as in EP, the condition tends to occur in perimenopausal women and has less of an association with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
  • Miscarriage and spontaneous abortion Spontaneous abortion Spontaneous abortion, also known as miscarriage, is the loss of a pregnancy before 20 weeks' gestation. However, the layperson use of the term "abortion" is often intended to refer to induced termination of a pregnancy, whereas "miscarriage" is preferred for spontaneous loss. Spontaneous Abortion: loss of pregnancy before 20 weeks’ gestation. Causes include maternal reproductive organ abnormalities and chromosomal aberrations. Bleeding and cramping are the most common symptoms. Beta HCG will be positive in both miscarriages and EP, but EP tends to be associated with smaller amounts of vaginal bleeding than miscarriages. Management is expectant, medical, or surgical, depending on the type of miscarriage.

Mnemonic

The mnemonic “HAIKU POEM” can help you remember the many differential diagnoses of an ectopic pregnancy. (A haiku is a traditional Japanese poem.)

Non-gynecological causes: HAIKU

  • H: Hepatitis 
  • A: Acute abdomen
  • I: Intestinal Inflammation (appendicitis, sigmoid diverticulitis)
  • K: Kidney stone 
  • U: Urinary tract infection

Gynecological causes: POEM

  • P: Pelvic inflammatory disease
  • O: Ovarian disease (cyst rupture, torsion, polycystic ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries)
  • E: Endometrial diseases ( endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis, hyperplasia)
  • M: Miscarriage/ spontaneous abortion Spontaneous abortion Spontaneous abortion, also known as miscarriage, is the loss of a pregnancy before 20 weeks' gestation. However, the layperson use of the term "abortion" is often intended to refer to induced termination of a pregnancy, whereas "miscarriage" is preferred for spontaneous loss. Spontaneous Abortion

References

  1. Tulandi, T. (2020). Ectopic pregnancy: Expectant management. UpToDate. Retrieved November 22, 2020, from Tulandi, T. (2020). Ectopic pregnancy: Expectant management. UpToDate. Retrieved November 22, 2020, from https://www.uptodate.com/contents/ectopic-pregnancy-expectant-management?search=ectopic%20pregnancy%20expectant%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 
  2. Sherwood, L. Human Physiology: From Cells to Systems. (9th ed., pp. 753, 756). Cengage Learning. 
  3. Marion, L. L., & Meeks, G. R. (2012). Ectopic pregnancy: History, incidence, epidemiology, and risk factors. Clinical obstetrics and gynecology, 55(2), 376–386. https://doi.org/10.1097/GRF.0b013e3182516d7b
  4. Farquhar C. M. (2005). Ectopic pregnancy. Lancet (London, England), 366(9485), 583–591. https://doi.org/10.1016/S0140-6736(05)67103-6
  5. Scibetta, E. W., & Han, C. S. (2019). Ultrasound in Early Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care: Viability, Unknown Locations, and Ectopic Pregnancies. Obstetrics and gynecology clinics of North America, 46(4), 783–795. https://doi.org/10.1016/j.ogc.2019.07.013

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