6.2 - Ectopic Pregnancy and PUL Flashcards
Define Ectopic Pregnancy
Implantation of a pregnancy outside the uterus
What is the most common site of an ectopic pregnancy?
What are other sites?
95% are tubal.
Most common is at the Ampulla of the fallopian tube (80%) and then at the isthmus (15%)
Extra tubal sites include interstitial and intermural (Within uterus), C-section scar, ovary, abdomen, cervix
What is the presentation of an ectopic pregnancy and what findings would you expect on exam
Presentation:
1) Abdominal pain of increasing intensity
2) Spotting/ PV bleed
3) Shoulder tip pain!!!
4) If ruptured -> Shock
Exam:
Vitals!: If ruptured, hypotension, tachycardia, tachypnoea, SOB, altered consciousness
Inspection: PV bleeding
Palpation: Abdominal tenderness +/- Rigidity
+/- Adnexal mass!
Bimanual: Cervical motion tenderness, enlarged uterus
Give 6 rf of an ectopic pregnancy
1) Tubal injury => PID or tubal surgery, or complication from previous surgery/adhesions
2) Cilia dysfunction => Smoking, CF, Primary cilliary dyskinesia
3) IVF or ICSI!!!
4) IUD
5) Prior ectopic pregnancy
A patient of 11 weeks gestation presents to the ED with acute onset lower abdominal pain and PV bleeding. What is your ddx?
Ddx for acute lower abdominal pain
1) Ovarian pathology (Ruptured corpus luteum cyst, ovarian torsion)
2) PID
3) Trauma
4) Endometriosis
Ddx for PV bleed in early pregnancy
1) Threatened miscarriage
2) Complete/inevitable miscarriage
3) Ectopic pregnancy
4) Molar pregnancy
5) Local causes (STI, infection, foreign body, cervical cancer)
the beta in B-hCG is specific to pregnancy.
What does it measure?
When is it detectable and When does it peak?
In the context of miscarriage and ectopic pregnancies, how would B-hCG help narrow your differentials?
B-hCG measures serum trophoblastic activity and is detectable 10 days after fertilization, peaking at 60 days
Normal Pregnancy: levels double every 48 hours
Ectopic pregnancy: Static or increases by less than 66% in 48 hours
Miscarriage: Decreasing beta HCG
State the ultrasound findings in ectopic pregnancy
beta hCG>1500 but no pregnancy in uterus. This means that
1) does not resemble normal IU pregnancy as 20% may have a pseudocyst
2) No yolk sac
3) No echogenic ring (amniotic sac)
4) No fetal pole (body => CRL)
How would you diagnose an ectopic pregnancy?
1) Focused hx and clinical exam
2) Labs -> urine to confirm pregnancy and serial serum B-hCG
+ rule out other ddx =>
b) APS!!! Antiphospholipid antibodies LAC and aCL
c) Karyotyping of parents and foetus (NIPT)
d) Thrombophilia screen
e) TFTs
f) HbA1C
3) TVUS - When beta hCG >1500 but no pregnancy in uterus
1) does not resemble normal IU pregnancy as 20% may have a pseudocyst
2) No yolk sac
3) No echogenic ring (amniotic sac)
4) No fetal pole (body => CRL)
+/-Adnexal mass otherwise PUL (pregnancy of unknown location)
How would you manage an ectopic pregnancy
It is important to determine if the patient is symptomatic or not (booking clinic for example) and has signs of shock as that would indicate an emergency and would need to be stabilized in ED before being transferred to theatre unless remains hemodynamically unstable. If not,
Expectant management: If beta hCG <1500 and Asymptomatic => Monitor as US findings are not present yet => of unknown viability
Medical: If symptomatic or beta hCG b/w 1500-5000 with adnexal mass <3.5cm => Give IM Methotrexate at 1mg/kg or 50mg/square meter (based on weight and height) !!!+Followup at 4 and 7 days then weekly until beta hCG <1500. Advise no sexual intercourse until then
Surgical: If beta hCG >5000 or Adnexal mass >3.5cm
a) If hemodynamically stable (including after stabilization in ED) -> Laparoscopy + Salpingostomy/salpingectomy
b) If hemodynamically unstable, laparotomy + Salpingostomy/salpingectomy
!!!+ Methotrexate administration
Why is methotrexate administered along with surgical management of ectopic pregnancy?
To prevent recurrence
What is the significance of followup in 4 and 7 days after administration of methotrexate?
When does the followup end?
What would you advise the woman until followup period ends?
After administration of methotrexate, beta hCG levels often rise for first 3-4 days before falling by day 7.
Followup continues weekly until beta hCG <1500
Advise women on medical management of ectopic pregnancy with methotrexate to not have sexual intercourse until beta hCG <1500
What are the contraindications to methotrexate administration?
What are the complications?
Contraindications:
1) Renal impairment
2) Liver impairment
3) Pulmonary fibrosis
4) Peptic ulcer disease
5) Bone marrow suppression
Complications:
1) Tubal rupture
2) Hepatotoxicity
3) Photosensitivity
4) Stomatitis
5) Bone marrow suppression
If given medical management of ectopic pregnancy with IM methotrexate and levels fail to fall after followup on day 7, what is your next step?
Re-administration of IM methotrexate of the same dose
Surgical option is offered to patient
How will you make the decision as to whether to go for salpingectomy or salpingostomy
Based on whether the contralateral tube is healthy
What is salpingostomy?
This procedure involves making an incision on the fallopian tube to remove the ectopic pregnancy without removing any part of the tube itself. After the ectopic tissue is extracted, the incision on the tube is usually left open to heal by secondary intention.
