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Ultrasonography can reliably demonstrate a gestational sac 6 weeks from the LMP and a fetal pole at 7 weeks if located in the uterus An empty uterine cavity raises a strong suspicion of extrauterine pregnancy, which can occasionally be revealed by endovaginal ultrasound Specified levels of serum hCG have been reliably correlated with ultrasound findings of an intrauterine pregnancy For example, an hCG level of 6500 mU/mL with an empty uterine cavity by transabdominal ultrasound is virtually diagnostic of an ectopic pregnancy Similarly, an hCG value of 2000 mU/ mL or more can be indicative of an ectopic pregnancy if no products of conception are detected within the uterine cavity by transvaginal ultrasound
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Repeat tubal pregnancy occurs in about 12% of cases This should not be regarded as a contraindication to future pregnancy, but the patient requires careful observation and early ultrasound confirmation of an intrauterine pregnancy
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Alleyassin A et al Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial Fertil Steril 2006 Jun;85(6):1661 6 [PMID: 16650421]
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With the advent of high-resolution transvaginal ultrasound, culdocentesis is rarely used in evaluation of possible ectopic pregnancy Laparoscopy is the surgical procedure of choice both to confirm an ectopic pregnancy and in most cases to permit pelviscopic removal of the ectopic pregnancy without the need for exploratory laparotomy
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Blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks of gestation Proteinuria of 03 g in 24 hours
Differential Diagnosis
Clinical and laboratory findings suggestive or diagnostic of pregnancy will distinguish ectopic pregnancy from many acute abdominal illnesses such as acute appendicitis, acute pelvic inflammatory disease, ruptured corpus luteum cyst or ovarian follicle, and urinary calculi Uterine enlargement with clinical findings similar to those found in ectopic pregnancy is also characteristic of an aborting uterine pregnancy or hydatidiform mole Ectopic pregnancy should be suspected when postabortal tissue examination fails to reveal placenta Steps must be taken for immediate diagnosis, including prompt microscopic tissue examination, ultrasonography, and serial hCG titers every 48 hours Patients must be warned of possible ectopic pregnancy problems and monitored very closely
Severe Preeclampsia
Blood pressure of 160 mm Hg systolic or 110 mm Hg diastolic Proteinuria 5 g in 24 hours or 4+ on dipstick Oliguria of < 500 mL in 24 hours Thrombocytopenia Hemolysis, elevated liver enzymes, low platelets (HELLP) Pulmonary edema Fetal growth restriction
Treatment
When a patient with an ectopic pregnancy is unstable or when surgical therapy is planned, the patient is hospitalized Blood is typed and cross-matched Ideally, diagnosis and operative treatment should precede frank rupture of the tube and intra-abdominal hemorrhage Surgical treatment is definitive In a stable patient, diagnostic laparoscopy is the initial surgical procedure performed Depending on the size of the ectopic pregnancy and whether or not it has ruptured, salpingostomy with removal of the ectopic or a partial or complete salpingectomy can usually be performed pelviscopically Clinical
General Considerations
Preeclampsia is defined as the presence of elevated blood pressure and proteinuria during pregnancy Eclampsia occurs with the addition of seizures Classically, the presence of three elements was required for the diagnosis of preeclampsia-eclampsia: hypertension, proteinuria, and edema Edema was difficult to objectively quantify and is no longer a required element
Obstetrics & Obstetric Disorders
Preeclampsia-eclampsia can occur any time after 20 weeks of gestation and up to 6 weeks postpartum It is a disease unique to pregnancy, with the only cure being delivery of the fetus and placenta Preeclampsia-eclampsia develops in approximately 7% of pregnant women in the United States Primiparas are most frequently affected; however, the incidence of preeclampsia-eclampsia is increased with multiple pregnancies, chronic hypertension, diabetes, renal disease, collagen-vascular and autoimmune disorders, and gestational trophoblastic disease Five percent of women with preeclampsia progress to eclampsia Uncontrolled eclampsia is a significant cause of maternal death The basic cause of preeclampsia-eclampsia is not known Epidemiologic studies suggest an immunologic cause for preeclampsia, since it occurs predominantly in women who have had minimal exposure to sperm (having used barrier methods of contraception) or have new consorts, in primigravidas, and in women both of whose parents have similar HLA antigens Preeclampsia is an endothelial disorder resulting from poor placental perfusion, which releases a factor that injures the endothelium, causing activation of coagulation and an increased sensitivity to pressors Before the syndrome becomes clinically manifest in the second half of pregnancy, there has been vasospasm in various small vessel beds, accounting for the pathologic changes in maternal organs and the placenta with consequent adverse effects on the fetus Recently,
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