2016 21 Ectopic Pregnancy Flashcards
1
Q
How is a tubal ectopic diagnosed?
A
- TVUS
- Adnexal mass moving separate to the ovary
- Progesterone not important
- β-hCG useful for Mx plan
2
Q
How is a cervical ectopic diagnosed?
A
- TVUS
- Empty uterus
- Barrel-shaped cervix
- Gestational sac below level of internal cervical os
- Absence of sliding sign
- Blood flow around GS on Doppler
3
Q
How is a Caesarean scar ectopic diagnosed?
A
- TVUS +/- TAUS
- MRI if diagnosis equivocal
- Empty uterine cavity
- GS or solid mass of trophoblast located anteriorly at level of internal os embedded at site of CS scar
- Thin or absent layer of myometrium between GS & bladder
- Prominent trophoblastic/ placental circulation on Doppler
- Empty endocervical canal
4
Q
How is an interstitial pregnancy diagnosed?
A
- TVUS
- Empty uterine cavity
- POC/GS located laterally in interstitial (intramural) part of tube, surrounded by <5mm myometrium in all planes
- Presence of interstitial line sign
- 3D US or MRI if needed
- β-hCG, repeat after 48 hours
5
Q
How is a cornual pregnancy diagnosed?
A
- TVUS
- Single interstitial portion of fallopian tube in main uterine body
- GS/POC seen mobile & separate from uterus & completely surrounded by myometrium
- Vascular pedicle adjoining GS to unicornuate uterus
- β-hCG
6
Q
How is an ovarian pregnancy diagnosed?
A
- No specific agreed criteria for US diagnosis
- β-hCG
- Generally diagnosed histologically following laparoscopy
7
Q
How is an abdominal pregnancy diagnosed?
A
- TVUS
- MRI if needed
- β-hCG raises suspicion
- Absence of intrauterine GS, dilated tube, complex adnexal mass
- Gestational cavity surrounded by loops of bowel, separated from them by peritoneum
- Wide mobility of sac
8
Q
How is a heterotopic pregnancy diagnosed?
A
- US findings of intrauterine & coexisting ectopic pregnancy
- β-hCG of limited value
9
Q
What surgical management is recommended for tubal ectopics?
A
- Laparoscopic over open
- Salpingectomy in preference to salpingotomy usually
- Consider salpingotomy if previous ectopic, contralateral tube damage, previous abdo surgery, PID
10
Q
What management is recommended for cervical ectopics?
A
- Methotrexate
- Surgery has high failure rate, reserve for life-threatening bleeding
11
Q
What are the management options for Caesarean scar ectopics?
A
- Counsel for severe M&M
- In 1st trimester, consider medical & surgical Mx +/- additional haemostatic measures
- Surgical generally more effective
12
Q
What are the management options for interstitial pregnancy?
A
- Expectant only if low/significantly falling β-hCG & methotrexate may not improve outcome
- Methotrexate good evidence
- Surgery: lap cornual resection or salpingotomy
- Consider hysteroscopic resection under lap or US guidance
13
Q
What are the management options for cornual pregnancy?
A
Excision of rudimentary horn via laparoscopy or laparotomy
14
Q
What are the management options for ovarian pregnancy?
A
- If laparoscopy needed to make diagnosis, then ideally operate
- Methotrexate if high surgical risk, or post-op if persistent residual trophoblast or raised β-hCG
15
Q
What are the management options for abdominal ectopic pregnancy?
A
- Laparoscopic removal
- Systemic methotrexate with US-guided fetocide
- Laparotomy for advanced abdo pregnancy
16
Q
What are the management options for heterotopic pregnancy?
A
- Include IUP in Mx plan
- Methotrexate only if IUP nonviable or unwanted
- Local injection of KCl or hyperosmolar glucose with aspiration of sac contents if woman is stable
- Surgical removal if unstable (or stable)
- Expectant Mx if nonviable
17
Q
When is anti-D indicated in Rh -ve women with ectopics?
A
- Surgical removal
- Bleeding repeated, heavy or associated with abdo pain
18
Q
What are the long-term fertility prospects following an ectopic?
A
- In absence of subfertility or tubal pathology, no difference in rates for different Mx options
- In subfertility, expectant or medical better
- Methotrexate has no impact on ovarian reserve
- UAE with methotrexate: live births still possible
- Ovarian with lap: good prospects
19
Q
What advice is given with methotrexate?
A
- Wait 3 months before TTC
- Muscle rekaxation training can help
20
Q
What is the incidence of ectopic pregnancy?
A
11 in 1000
21
Q
What are the risk factors for ectopic pregnancy?
A
- Tubal damage following surgery
- Infection
- Smoking
- IVF
However, majority have no risk factors
22
Q
How can an early IUP be distinguished from a pseudosac?
A
- Intradecidual sign: fluid collection with echogenic rim, within thickened decidua on 1 side of cavity
- Double decidual sign: intrauterine fluid collection surrounded by 2 concentric echogenic rings
23
Q
What is the sliding sign?
A
TVUS prove pressure against cervix
Miscarriage GS slides against endocervical canal
Cervical ectopic does not
24
Q
In cervical ectopic, what β-hCG level is associated with a decreased level of successful methotrexate Tx?
A
> 10,000
25
What is the prevalence of CS pregnancy?
1:2000
26
What proportion of ectopic pregnancies are cervical?
<1%
27
What proportion of ectopic pregnancies are interstitial?
1-6%
28
Describe the interstitial portion of the fallipian tube
1-2cm length
Traverses muscular myometrium of uterine wall
Opens via tubal ostium into uterine cavity
29
What is the interstitial line sign?
Thin echogenic line
Extending from central uterine cavity echo
To periphery of interstitial sac
30
What is the single dose protocol for IM methotrexate?
D1: serum β-hCG, U&E, LFT, FBC, G&S, 50mg/m2 IM methotrexate
D4: serum β-hCG
D7: serum β-hCG
If <15% decrease, repeat TVS & Tx
If > 15% decrease, weekly levels til < 15
31
What are the contraindications to methotrexate?
1. Haemodynamic instability
2. Presence of IUP
3. Breastfeeding
4. Unable to comply with follow-up
5. Known sensitivity
6. Chronic liver disease
7. Pre-existing blood dyscrasia
8. Active pulmonary disease
9. Immunodeficiency
10. Peptic ulcer disease
32
What are the predictors of successful methotrexate Tx for ectopic pregnancy?
1. Lower serum β-hCG level
2. US appearance of ectopic: absence of yolk sac, fetal pole, cardiac activity
3. Pre-Tx changes in β-hCG level: smaller increases
4. Decrease in β-hCG levels from D1 to D4
33
What are the common adverse effects of methotrexate?
1. Excessive flatulence
2. Bloating
3. Transient rise in liver enzymes
4. Stomatitis
34
What are the common adverse effects of methotrexate?
1. Excessive flatulence
2. Bloating
3. Transient rise in liver enzymes
4. Stomatitis
35
What are rarer adverse effects of methotrexate?
1. Bone marrow suppression
2. Pulmonary fibrosis
3. Nonspecific pneumonitis
4. Liver cirrhosis
5. Renal failure
6. Gastric ulceration
36
Under what conditions is methotrexate first-line Tx for an ectopic?
1. No significant pain
2. Unruptured & <35mm with no visible heartbeat
3. β-hCG between 1500 & 5000
4. No IUP
5. Able to return for follow-up
37
What are the conditions for expectant Mx of ectopic pregnancy?
1. Clinical stability
2. No pain
3. No significant haemoperitoneum
4. <30mm
5. β-hCG < 1500
38
What is the rate of recurrent ectopic pregnancy?
18.5% regardless of treatment modality
