The other big diagnostic tool for ectopic pregnancy
is checking a serum HCG.
HCG is a hormone secreted from the growing fetus.
And in the first 6-7 weeks of pregnancy
the beta HCG will double every 1.8 to three days.
So you can follow serial levels.
In the Emergency Department on that first visit,
you’re just gonna be able to get one discreet level
but there's a following of serial level.
So following levels for patients
if they're discharged
or even if they have an ectopic pregnancy
that’s treated can be very helpful.
Because you wanna see in a normal pregnancy,
those levels will double that every 1.8 to 3 days.
But in an abnormal pregnancy like an ectopic pregnancy,
those levels will not be doubling,
those levels will be going down.
So what does the HCG level tell you
about what you should see on your ultrasound?
So for normal intrauterine pregnancy,
that’s a pregnancy that’s implanted in the right place
that’s developing normally.
On a transvaginal ultrasound,
you would start to see stuff at a levels 1.000-2.000.
However, ectopic pregnancy has been diagnosed
at very low levels of HCG.
So what is this telling us
is that we don’t wanna go ahead and use our HCG levels
to talk us out of getting an ultrasound
or to tell us not to get an ultrasound
or for us to call our radiologist to say,
"Well, the HCG is 500. We’re not gonna get an ultrasound."
Ectopic pregnancy can be diagnosed at very low levels.
It will help you interpret what you see the HCG.
But it won’t necessarily
or should never talk you out of getting a test.
I personally have diagnosed ectopic pregnancy in a patient
who had an HCG level of 250.
And I know people who have anecdotally
had ectopic pregnancies diagnosed with levels in that range.
So go ahead and check the level, but don’t let it use you.
Don’t use it to talk you out of getting the test.
What other blood work should you get for your patient?
So you’re working on getting an ultrasound,
you’ve checked the HCG level.
You wanna check a CBC.
Now even in ruptured ectopic pregnancy
the hemoglobin maybe normal.
And the reason for that
is that it takes our body sometimes a little bit
to equilibrate, and have that hemoglobin have her reflect
and have it dropped and have the bare reflection of the bleeding.
The other very important lab to send is the type and screen.
And the reason why we send the type and screen
for all patients with vaginal bleeding in pregnancy
is to prevent the blood type from the mother
reacting with the blood type from the baby.
So if someone has a negative blood type,
so if they’re A negative,
O negative, that patient will need RhoGam.
And the reason we give Rhogam
is we use it to prevent future Rh incompatibility.
'Cause the issue would be,
if the baby had positive blood,
so the fetus that’s developing has positive blood
and the mother has negative blood
and those blood types get exposed to one another.
They can react to one another.
And then the mom can make anti-bodies to that blood type
and if she were to get pregnant again,
then that will cause issues with future pregnancy.
You know, if you’re concerned
that the patient will need surgery or a blood transfusion,
a type and cross maybe beneficial.
So the type and screen tells you the blood type
and whether the patient has a negative or a positive blood type.
Type and cross is when you start
getting blood ready for the patient.
So that’s when you start preparing the blood.
Now the ultrasound is your test of choice
in your imaging modality of choice to diagnose it.
Ultrasound will show an ectopic pregnancy
either in the fallopian tube
or within the corner of the uterus.
it will look like a gestational sack
or a very early developing fetus in that area.
Sometimes, depending on how far the pregnancy is advanced,
you’ll see fetal heart [tones 03:58.18] as well.
You know, this ultrasound is actually an example
of an indeterminate ultrasound.
So what happens with some people
who present vaginal bleeding in early pregnancy
is you’ll get the ultrasound
and the ultrasound will show an empty uterus.
It won’t show anything in the uterus.
It won’t show a normal intrauterine pregnancy.
But it also doesn’t show an ectopic pregnancy.
So we wanna be thinking about
what we’re gonna do for these patients
and how we're gonna advise them
'cause we don’t have a clear diagnosis right now.
So if your ultrasound is indeterminate,
so what we mean by that is you do the ultrasound
and you don’t see an ectopic pregnancy
and you don’t see something in the uterus.
is a more likely if the HCG levels are less than a thousand.
You know, if your HCG levels are above 1.000
or above that discriminatory zone at 1.000-2.000 range,
you might be starting to wonder where the pregnancy in fact is.
In those situations,
you may need to consult OBGYN to help them sort out
what the next best steps are for that patient.
Now, if your patient is unstable
or there’s evidence of irritation to the peritoneal cavity.
So their belly is tense and rigid,
they have a lot of guarding or rebound tenderness.
The next step here should be a point of care ultrasound fast
in the ED to look for free fluid.
So what that is,
the fast scan is discussed in other lectures on trauma.
But what it looks for
is it looks for free fluid in the abdomen.
So if someone has a ruptured ectopic pregnancy,
they're gonna have blood in their abdomen.
So that point of care ultrasound fast can do a good job
at looking and seeing
if there's any blood in the abdominal cavity.
Now again, if you see blood in the abdominal cavity
and that patient has a positive pregnancy test
and they’re unstable, you get on the phone
and you get your patient to the operating room
as quickly as possible.
You know, if the work up is unrevealing,
so let’s say, you’re not really sure what’s going on.
The ultrasound isn’t very revealing,
the patient's lab value aren’t super revealing,
but your patient is unstable.
So they still are hypotensive,
That patient may benefit from a diagnostic laparoscopy.
So what basically happen's there is the OBGYN team
goes in to the abdomen and they take a look.
And they see if there’s any evidence of bleeding
or any concerns that weren’t seen necessarily
on the other imaging studies.
Laparoscopy is the surgery that takes place using the cameras.
So the patient won’t have a big open scar
or anything along those lines in case something isn’t found.
Beware of the heterotopic pregnancy.
So heterotopic pregnancy,
what that means is it means that
you have one pregnancy that’s implanted in the uterus.
So one intrauterine pregnancy and one ectopic pregnancy.
So the patient essentially has two pregnancies in the body.
One being normal and one being implanted in an abnormal place.
You know, this is relatively rare in spontaneous conceptions.
I actually have taken care of one individual in my life
that's had this via a spontaneous conception.
But there's increase incidents of this in patients
who are undergoing in-vitro fertilization.
Always make sure that you’re thinking about this.
This is another one of those reasons that I go ahead
and I get formal ultrasounds almost all the time
in these patients,
because even though I see something in the uterus
that doesn’t necessarily always rule out the fact
that there could also be an ectopic pregnancy.
So go ahead, think about this.
You may or may not ever see it.
It’s a relatively rare diagnosis.
But it’s something
that can be very life threatening to the patient.