1.02 Complications of Early Pregnancy- Ectopic Pregnancy

Question 1

Most common location of ectopic pregnancy

Answer 1

Tubal

Question 2

How is heterotrophic pregnancy handled?

Answer 2

The ectopically implanted conceptus will be treated while the intrauterine pregnancy will not be treated

Question 3

At what age increases the risk for ectopic pregnancy?

Answer 3

35 years old

Question 4

Classic triad of ectopic pregnancy

Answer 4

Delayed menstruation
Pain
Vaginal bleeding/spotting

Question 5

What is culdocentesis for?

Answer 5

It checks abnormal fluid in the posterior fornix (cavity behind the uterus) > any bloody fluid that does not clot or old clots indicate ectopic pregnancy

However, it cannot detect unruptured ectopic pregnancy as it does not bleed

Question 6

Inhomogenous mass with a classic ring of fire on ultrasound indicates what?

Answer 6

Increased vascularity -> ectopic pregnancy

Question 7

T/F: In early pregnancy, bHcG levels increase in a curvilinear fashion until a platue at 1,000 mIU/mL is reached by 10weeks of gestation

Discriminatory threshold of b-hCG

T/F: Serial bhCG increases by 50% every 24 hrs

Answer 7

F
- it’s 100,000 mIU/mL

threshold- 3500 mIU/mL

F- every 48 hours

Question 8

Progesterone value for nonliving/ectopic pregnancy:

For normal pregnancy:

Answer 8

Non-living/ectopic pregnancy: <5ng/mL
Normal: >25 ng/mL

Question 9

What to do with hemodynamically unstable patient with positive pregnancy test + abdominal pain + vaginal bleeding

Answer 9

Culdocentesis > surgery if positive

Question 10

What to do with hemodynamically stable patient with positive pregnancy test + abdominal pain + vaginal bleeding

Answer 10

TVS

If IUP > prenatal care
If abnormal (abortion) > treat
If nondiagnostic > measure bHCG

Question 11

T/F: Single-dose methotrexate is the preferred option over multidose due to its less risk for adverse events

Single best prognostic factor for successful treatment of methotrexate:

Answer 11

T

b-HCG levels = must be declining upon measurement on days 1, 4, and 7 in single dose protocol; weekly surveillance afterwards

Question 12

T/F: Methotrexate can be used for heterotrophic pregnancy

Methotrexate dosage for single dose

Methotrexate dosage for multidose

Answer 12

T

Single dose: 50 mg/m2 BSA on day 1

Multidose: 1mg/kg on days 1,3,5,7
0.1 mg/kg on days 2,4,6,8

Question 13

Indications for additional doses for single and multidoses of methotrexate

Answer 13

Single dose: add dose if serum b-hCG did not decline by 15% from day 4 to day 7; or less than 15% decline during weekly surveillance

Multidose: add dose if serum bHCG declines less than 15%; repeat serum hCG in 48 hours and compare previous doses; max 4 doses

Question 14

T/F: You can take methotrexate while breastfeeding

T/F: Methotrexate is contraindicated to ruptured ectopic pregnancy

Answer 14

F- absolute contraindications include breastfeeding

T

Question 15

What are the relative contraindications for methotrexate use?

Answer 15

If there is embryonic cardiac activity on TVS
High intial bhCG concentration (5000-10000)
Ectopic pregnancy greater than 4mm size in TVS
Refusal to accept blood transfusion

Question 16

This ectopic pregnancy is where the implant lies within the muscular uterine wall of a uterus within the proximal tube segment with a Mullerian Abnormality

What kind of resection is done?

Answer 16

Interstitial Pregnancy

Cornual resection

Question 17

Criteria for interstitial pregnancy include >___ cm away from the most lateral edge of the uterine cavity and thin (<___mm) myometrial mantle surrounding the sac

Answer 17

> 1cm away
<5mm thin

Question 18

The placenta, gestational sac, or both are embedded in the hysterectomy scar

Answer 18

Cesarean scar pregnancy

Question 19

T/F: Methotrexate works on cesarean scar pregnancy

Answer 19

F- needs to be evacuated

Question 20

What is the Rubins Criteria for Cervical pregnancy?

Answer 20

-The cervical glands must be opposite to the attachment of trophoblast/placenta
-The attachment of trophoblasts must be below the level of entrance of uterine vessels into the uterus or anterior peritoneal reflection
-Fetal elements must be absent form the corpus uteri

Question 21

T/F: Methotrexate can be used for cervical pregnancy

Surgical Tx:

Answer 21

T

Hysteroscopy (camera-guided curettage)

Question 22

Where is spiegelberg Criteria used?

What are the mentioned criteria?

Answer 22

For ovarian pregnancy

-Ipsilateral tube must be intact and distinct from the ovary
-There should be a gestational sac in the ovary
-The ectopic pregnancy is connected by the utero-ovarian ligament to the uterus
-Ovarian tissue can be identified histologicallly despite the placental tissue

Question 23

Where is the Studdiford Criteria used?

What are its criteria?

Answer 23

for Abdominal Pregnancy

-The presence of normal bilateral tubes and ovaries with no evidence of recent or past pregnancy
- No evidence of uteroperitoneal fistula
-Presence of pregnancy related exclusively to the peritoneal surface, early enough to eliminate the secondary implantation after primary tubal nidation