25. Ectopic Pregnancy Flashcards
What is the definition of an ectopic pregnancy?
Any pregnancy that occurs outside the uterine cavity.
Where can ectopic pregnancies implant?
- Fallopian tubes (most common)
- Cornua of the uterus
- Cervix
- Ovary
- Abdominal cavity (extra-uterine)
What is a chronic ectopic pregnancy?
A condition where the conceptus is resorbed, but adhesion formation leads to a painful mass.
What is the most common cause of ectopic pregnancy in the patient population?
Pelvic Inflammatory Disease (PID).
How does PID contribute to ectopic pregnancy?
Acute salpingitis (inflammation of the fallopian tubes) leads to adhesions within hours of infection with Chlamydia or Gonococcus, impairing tubal transport.
What is the risk of a repeat ectopic pregnancy after a previous one?
25% risk of another ectopic pregnancy.
How does progestogen-only contraception contribute to ectopic pregnancy risk?
It may slow tubal motility, increasing the chance of ectopic implantation. However, overall, it effectively prevents pregnancy and reduces overall ectopic risk.
What other factors increase the risk of ectopic pregnancy?
- Previous pelvic surgery leading to adhesions
- Anatomical distortion of the fallopian tubes due to endometriosis
- Assisted reproductive techniques (due to drugs used or underlying tubal damage)
- Current use of an Intrauterine Contraceptive Device (IUCD) (mild association)
How does the incidence of ectopic pregnancy relate to PID?
It is directly proportional to PID incidence and is increasing due to the rising prevalence of pelvic infections.
What is the approximate incidence of ectopic pregnancy?
1% of conceptions result in ectopic pregnancy.
What are the classic symptoms of ectopic pregnancy?
- Amenorrhoea
- Unilateral pelvic pain
- Collapse (in severe cases)
What are the clinical signs of a ruptured ectopic pregnancy?
- Shock
- Pelvic peritonitis
- Cervical excitation tenderness
- Palpable unilateral pelvic mass (may not always be elicited due to tenderness)
Why is a high index of suspicion required for ectopic pregnancy?
Presentation can be subtle, and symptoms vary widely.
In which women should ectopic pregnancy always be suspected?
Any sexually active woman (even if using contraception) presenting with:
- Abnormal vaginal bleeding
- Pelvic pain
- Possible or unrecognized pregnancy
What gynaecological conditions should be considered in the differential diagnosis of ectopic pregnancy?
- Pelvic Inflammatory Disease (Always do a pregnancy test!)
- Rupture, haemorrhage, or torsion of an ovarian cyst
- Threatened or inevitable miscarriage
- Red degeneration of a fibroid in pregnancy (rare in the first trimester)
- Gestational trophoblastic disease with corpus luteal cyst complications
What should always be assumed in a pregnant woman with pain and bleeding until proven otherwise?
An ectopic pregnancy.
Why should pelvic examination be performed gently in suspected ectopic pregnancy?
To avoid rupturing an intact ectopic gestational sac.
How can a pregnancy test help in diagnosing an ectopic pregnancy?
A sensitive urine test (25-50 IU/ml) can establish pregnancy, but a serum β-hCG is more accurate.
What should be done if a urine pregnancy test is equivocal?
Check serum β-hCG levels and repeat in 48 hours if necessary.
What is the expected rise in β-hCG in a viable intrauterine pregnancy?
Previously: Doubling every 48 hours.
Now: A rise of ≥66% is considered normal, but a rise <53% suggests a non-viable pregnancy (ectopic or miscarriage).
Can β-hCG levels alone rule out ectopic pregnancy?
No. Ruptured and unruptured ectopic pregnancies have been identified with β-hCG levels from <100 IU/L to >50,000 IU/L.
What is the main purpose of an ultrasound in suspected ectopic pregnancy?
To determine if there is an intrauterine pregnancy (IUP).
What ultrasound findings suggest an ectopic pregnancy?
- No intrauterine gestational sac with a positive pregnancy test.
- Adnexal mass (especially with fetal heart activity).
- Free fluid in the pelvis.
At what β-hCG level should an intrauterine pregnancy be visible on ultrasound?
- Vaginal scan: ≥1500 IU/L.
- Abdominal scan: ≥6500 IU/L.
What does failure to detect an intrauterine pregnancy at these levels suggest?
Ectopic pregnancy.
When is laparoscopy/laparotomy needed for ectopic pregnancy?
If the diagnosis remains unclear after other investigations.
What is the benefit of laparoscopy in suspected ectopic pregnancy?
It provides a definitive diagnosis and allows for immediate surgical removal.
What test can be used if ultrasound and laparoscopy are unavailable?
Colpo-puncture (aspiration from the pouch of Douglas).
What does the presence of blood or serum in the colpo-puncture suggest?
Possible ectopic pregnancy, requiring further investigation.
What is the role of D&C in ectopic pregnancy diagnosis?
Chorionic villi in endometrial tissue confirm intrauterine pregnancy.
Absence of chorionic villi suggests an ectopic pregnancy.
When can expectant management be considered?
- Patient is stable.
- Low β-hCG levels.
- Spontaneous regression expected.
- Requires close follow-up
What is a major disadvantage of expectant management?
Longer hospital stay with risk of rupture.
What is the most commonly used medical treatment for ectopic pregnancy?
Methotrexate (a folic acid antagonist).
How does Methotrexate work?
Disrupts DNA/RNA of rapidly dividing trophoblastic cells.
What are other agents used for medical management?
Hyperosmolar glucose, prostaglandins, mifepristone (anti-progesterone).
❓ What are the eligibility criteria for medical therapy?
✅ - Easy follow-up.
✅ - Minimal symptoms.
✅ - β-hCG < 3000 IU/L (RCOG Guideline).
✅ - No contraindications to cytotoxic agents (e.g., liver disease, myelosuppression).
Why should contraception be used for at least three months after Methotrexate?
To prevent teratogenic effects in future pregnancies.
What is the immediate surgical approach for a ruptured ectopic pregnancy?
Emergency laparotomy with resuscitation.
What procedure is commonly performed in ruptured ectopic pregnancy?
Partial salpingectomy (removal of part of the fallopian tube).
When is laparotomy necessary?
✅ - Shock due to rupture.
✅ - Chronic ectopic pregnancy with dense adhesions or complex mass.
What is the modern surgical approach for stable/unruptured ectopic pregnancy?
Laparoscopic excision or partial salpingectomy.
What are the advantages of laparoscopic surgery over laparotomy?
✅ - Better cosmetic results.
✅ - Shorter hospital stay.
✅ - Faster return to normal activities.
✅ - Lower postoperative pain and morbidity.
What is the key strategy to prevent ectopic pregnancy?
Reducing the incidence of PID through condom use in non-monogamous relationships.
Why is early ultrasound important in women with a history of ectopic pregnancy?
To confirm intrauterine pregnancy early and reduce the risk of undiagnosed ectopic pregnancy.
What should healthcare workers remember about ectopic pregnancy?
It is a subtle but dangerous condition, requiring high vigilance.
What should be suspected in a young patient with lower abdominal pain and a positive pregnancy test?
Ectopic pregnancy!
❓ What historical factors increase ectopic pregnancy risk?
✅ - Previous ectopic pregnancy
✅ - Previous tubal ligation (T/L)
✅ - IUCD use
✅ - History of PID
What clinical signs should be assessed?
✅ - Pallor
✅ - Pulse & BP
✅ - Hemoglobin
✅ - Pelvic tenderness
❓ What is the first step in suspected ectopic pregnancy?
Establish IV access and assess patient stability.
What is the immediate management for a shocked patient?
Resuscitate & prepare for emergency surgery.
What is the next step in a stable patient?
Perform a transvaginal ultrasound (TVS) to look for intrauterine pregnancy (IUP).
What does an empty uterus or no ultrasound availability indicate?
Perform quantitative βhCG testing.
What are the differential diagnoses if no intrauterine pregnancy is found?
✅ - Ectopic pregnancy
✅ - Missed miscarriage
✅ - Early pregnancy (if no TVS done)
What is the significance of βhCG ≤ 1500 IU?
Repeat βhCG in 48 hours.
❓ What does a βhCG rise of >66% in 48 hours indicate?
✅ Likely a viable intrauterine pregnancy (IUP).
What does a βhCG rise of <53% in 48 hours indicate?
Possible ectopic or non-viable pregnancy.
When should a repeat scan be performed?
If βhCG > 1500 IU and no intrauterine pregnancy seen.
What clinical signs require urgent intervention?
✅ - Increasing pain/tenderness
✅ - Drop in hemoglobin
✅ - Hypotension & tachycardia
❓ If in doubt, what is the definitive diagnostic procedure?
✅ Laparoscopy or laparotomy.
