11. Ectopic Pregnancy Flashcards
Define: Ectopic pregnancy (1)
- embryo implants outside of the endometrial cavity
Name normal sites of implantation for ectopic pregnancy (7)
Name sites of ectopic pregnancy implantation in order of frequency (6)
ampullary (70%) >> isthmal (12%) > fimbrial (11%) > ovarian (3%) > interstitial (2%) > abdominal (1%)
Describe epidemiology: Ectopic Pregnancy (4)
- 1/100 pregnancies
- fourth leading cause of maternal mortality, leading cause of maternal death in first trimester
- increase in incidence over the last 3 decades
- three commonest locations for ectopic pregnancy: ampullary (70%), isthmic (12%), fimbrial (11%)
Describe etiologies: Ectopic Pregnancy (4)
- 50% due to damage of fallopian tube cilia following PID
- intrinsic abnormality of the fertilized ovum
- conception late in cycle
- transmigration of fertilized ovum to contralateral tube
Describe algorithm for suspected ectopic pregnancy (figure)
Name: Contraindications to Methotrexate Therapy for Ectopic Pregnancy (8)
- Abnormalities in hematologic, hepatic or renal function
- Immunodeficiency
- Active pulmonary disease
- Peptic ulcer disease
- Hypersensitivity to methotrexate
- Heterotopic pregnancy with coexisting viable intrauterine pregnancy
- Breastfeeding
- Unwilling or unable to adhere to methotrexate protocol
Name risk factors: Ectopic pregnancy (6)
- previous ectopic pregnancy
- gynecologic
- current IUD use – increased risk of ectopic if pregnancy occurs
- history of PID (especially infection with C. trachomatis), salpingitis
- infertility
- infertility treatment (IVF pregnancies following ovulation induction (7% ectopic rate))
- previous procedures
- any surgery on fallopian tube (for previous ectopic, tubal ligation, etc.)
- abdominal surgery for ruptured appendix, etc.
- smoking
- structural
- uterine leiomyomas
- adhesions
- abnormal uterine anatomy (e.g. T-shaped uterus)
Describe investigations: Ectopic pregnancy (4)
- serial β-hCG levels; normal doubling time with intrauterine pregnancy is 1.6-2.4 d in early pregnancy
- rise of <20% of β-hCG (1.6-2.4 d) is 100% predictive of a non-viable pregnancy
- prolonged doubling time, plateau, or decreasing levels before 8 wk implies nonviable gestation but does not provide information on location of implantation
- 85% of ectopic pregnancies demonstrate abnormal β-hCG doubling
- ultrasound
- U/S is only definitive if fetal cardiac activity is detected in the tube or uterus
- specific finding on transvaginal U/S is a tubal ring
- suspect ectopic in case of empty uterus by TVUS with β-hCG >2000-3000 mIU/ml
- laparoscopy (sometimes used for definitive diagnosis)
Describe treatment: Ectopic pregnancy (4)
- goals of treatment: conservative (preserve tube if possible), maintain hemodynamic stability
- surgical = laparoscopy
- linear salpingostomy an option if tube salvageable, however, patient must be reliable to follow-up with weekly β-hCG
- salpingectomy if tube damaged or ectopic is ipsilateral recurrence
- 15% risk of persistent trophoblast if salpingectomy; must monitor β-hCG titres weekly until they reach non-detectable levels
- consider Rhogam® if Rh negative
- patient may require laparotomy if unstable, extensive abdominal surgical history, etc.
- medical = methotrexate
- use 50 mg/m2 body surface area; given in a single IM dose
- this is 1/5 to 1/6 chemotherapy dose, therefore minimal side effects (reversible hepatic dysfunction, diarrhea, gastritis, dermatitis)
- follow β-hCG levels weekly until β-hCG is non-detectable
- plateaued or rising levels suggest persistent trophoblastic tissue requiring further treatment
- 82-95% success rate, but up to 25% will require a second dose
- administer a second dose if β-hCG does not decrease by at least 15% between days 4 and 7
- tubal patency following methotrexate treatment approaches 80%
- expectant management is an option for patients who are clinically stable, reliable for follow-up, and have β-hCG levels that are low and declining
Describe prognosis: Ectopic pregnancy (3)
- 9% of maternal deaths during pregnancy attributed to ectopic pregnancy
- 40-60% of patients will become pregnant again after surgery
- 10-20% will have subsequent ectopic pregnancy
Any woman presenting with abdominal pain, vaginal bleeding and amenorrhea is ___ until proven otherwise
an ectopic pregnancy
Describe: Presentation of Ectopic Pregnancy Ruptures (3)
- Acute abdomen with increasing pain
- Abdominal distention
- Shock
Describe: Management of Abortions (3)
- Always rule out an ectopic
- Always check Rh; if negative, give Rhogam®
- Always ensure patient is hemodynamically stable