Educational Case: Ectopic pregnancy and its relation to pelvic infections.

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A 23-year-old woman presents to the emergency department with right-sided lower abdominal pain. Her pain began insidiously last night and has increased drastically in the past 12 hours. The pain is only on the right side. She indicates that she has been mildly febrile, nauseated, and fatigued. She does not report having diarrhea, dark or bloody stools, dysuria, hematuria, or chills. She has a history of irregular menstrual cycles. Her last known menstrual period was 9 weeks ago. She began spotting two days prior thinking this was her cycle. However, she has only continued to spot and has not experienced her normal amount of menstruation. The pain is unlike previous menstrual cramps. She is sexually active and occasionally uses condoms for contraception. She is unsure if she has previously had a sexually transmitted infection (STI); she has not been tested in the past year.

Objective FDP1.1: Ectopic Pregnancy. Describe the risk factors, characteristic morphologic findings, potential outcomes, and the medical/surgical options for the management of ectopic pregnancy in relation to the pathogenesis and likelihood of adverse consequences. Competency 2: Organ system pathology; Topic: Female reproductive—Disorders of pregnancy (FDP): Learning goal I: Disorders of pregnancy.

• There can be multiple causes for abdominal pain, including appendicitis, ectopic pregnancy, or a ruptured ovarian cyst. Evaluation of all potential causes is important for making a clear diagnosis. • Imaging with ultrasound, MRI, or CT can help in having a clear diagnosis and rule out possible high-risk causes of abdominal pain. CT use in pregnancy is not a preferred option. • On ultrasound, a nonhomogeneous adnexal mass, with or without cardiac activity, and an empty intrauterine space is highly indicative of an ectopic pregnancy. • Characteristic morphologic findings of an ectopic pregnancy in a fallopian tube are a dilated, distended tube, possible rupture site, and the presence of blood clot, embryo, and chorionic villi in the tube. • The outcomes of an ectopic pregnancy may include tubal rupture, which can lead to major internal bleeding. Some ectopic pregnancies may end on their own. • Surgical options to treat an ectopic pregnancy include salpingostomy with removal of the products of conception or salpingectomy. • Methotrexate is the nonsurgical treatment for ectopic pregnancy and requires extremely close follow-up, which may be a barrier to care for some patients. • Patients should be followed and monitored closely for downward trending hCG levels and for signs of ruptured ectopic pregnancy, after methotrexate therapy. • Risk factors for an ectopic pregnancy include a prior ectopic pregnancy, tubal scarring from infection, abdominal surgery or endometriosis, and the presence of an IUD. • PID increases the risk for ectopic pregnancy through host-inflicted damage to cells. This can cause loss of ciliation and scar tissue formation within the fallopian tube preventing the embryo from implanting in the uterus. • Treatment of PID includes coverage of aerobic and anaerobic pathogens. • Yearly testing for Neisseria gonorrhoeae and Chlamydia trachomatis should be done by providers for sexually active patients, especially those under 25. Consistent condom use should also be discussed with patients even if they are on another form of birth control. There can be multiple causes for abdominal pain, including appendicitis, ectopic pregnancy, or a ruptured ovarian cyst. Evaluation of all potential causes is important for making a clear diagnosis. Imaging with ultrasound, MRI, or CT can help in having a clear diagnosis and rule out possible high-risk causes of abdominal pain. CT use in pregnancy is not a preferred option. On ultrasound, a nonhomogeneous adnexal mass, with or without cardiac activity, and an empty intrauterine space is highly indicative of an ectopic pregnancy. Characteristic morphologic findings of an ectopic pregnancy in a fallopian tube are a dilated, distended tube, possible rupture site, and the presence of blood clot, embryo, and chorionic villi in the tube. The outcomes of an ectopic pregnancy may include tubal rupture, which can lead to major internal bleeding. Some ectopic pregnancies may end on their own. Surgical options to treat an ectopic pregnancy include salpingostomy with removal of the products of conception or salpingectomy. Methotrexate is the nonsurgical treatment for ectopic pregnancy and requires extremely close follow-up, which may be a barrier to care for some patients. Patients should be followed and monitored closely for downward trending hCG levels and for signs of ruptured ectopic pregnancy, after methotrexate therapy. Risk factors for an ectopic pregnancy include a prior ectopic pregnancy, tubal scarring from infection, abdominal surgery or endometriosis, and the presence of an IUD. PID increases the risk for ectopic pregnancy through host-inflicted damage to cells. This can cause loss of ciliation and scar tissue formation within the fallopian tube preventing the embryo from implanting in the uterus. Treatment of PID includes coverage of aerobic and anaerobic pathogens. Yearly testing for Neisseria gonorrhoeae and Chlamydia trachomatis should be done by providers for sexually active patients, especially those under 25. Consistent condom use should also be discussed with patients even if they are on another form of birth control.

Objective FU4.1: Clinical features of pelvic infections. Discuss common pelvic infections, including those affecting the vulva, vagina, cervix, and fallopian tubes, and describe the pathogenesis of pelvic inflammatory disease, common organisms involved, and its complications. Competency 2: Organ system pathology; Topic: Female reproductive—Uterus, cervix, and vagina (FU): Learning goal 4: Female genital tract.

The patient recovered well. Serial hCG performed post-op day 2 was down from 2,700 mIU/mL to 352 mIU/mL. She was discharged from the hospital with a birth control prescription. Serum hCG on post-op day 4 in outpatient clinic was undetectable. Her postoperative course was without complications. She healed well and reported feeling back to normal at her 6-week post-op visit. She continued to have yearly screening for ChT and NG as recommended by the Centers for Disease Control and Prevention. This would ensure that if reinfection were to occur, it would be detected early and treated effectively.

There are no conflicts of interest to declare on behalf of either Dr. Liana Haven or Dr. Susan Roe.

Currently, the CDC recommends all patients with a uterus who are 25 or younger and sexually active receive yearly screening for ChT and NG regardless of relationship status. 5 , 7 , 8 Bacterial vaginosis does not fall into yearly screening and is only recommended to be tested for if a patient is symptomatic. 8 For those over the age of 25, testing is recommended for those with new or multiple partners, inconsistent condom use, previous STI diagnosis, or if a partner had a positive STI test. 8