Acute abdo - ectopic

Question 1

Hx: patient presents with unilateral lower pain (LIF), dark PV bleeding, pain on defecation and urination, and dizziness/syncope?

+/- shoulder tip pain
+/- D, V

Ex:
+/- cervical excitation
(rarely +/- adnexal mass)

Answer 1

ectopic
(many are ASx)
(amenorrhoea 6-8 weeks)

Question 2

ectopic presenting with peritonism and shock (HR, BP, etc)?

Answer 2

sudden ectopic rupture

Question 3

risk factors? “ecTOPICS”

Answer 3

Tubal ligation/surgery
Ovulation induction (IVF)
PMHx ectopic, endometriosis
Inflammation (PID)
Coil (IUCD)
Smoking

• anything that slows passage of ovum to uterus

Question 4

Ix ectopic?

Answer 4

BEDSIDE:
• do a PV exam and speculum!!!! (doesn’t rupture)
• urine B-hCG

BLOODS:
• serum B-hCG - serial tests if US doesn’t confirm intrauterine pregnancy
- falling values suggest miscarriage
- slow rising suggests ectopic
• FBC, group and save + crossmatch 6U, IVT
• serum progesterone <20 (helps show failing pregnancy)

IMAGING:
• TVUS (most sensitive to confirm viable intrauterine pregnancy)
• abdo US alternative
• possible laparoscopy if unknown location

Question 5

Tx ectopic?

Answer 5

conservative:
• B-hCG <1000 and falling
• no Sx, small mass <3cm
• follow-up to ensure B-hCG dropping (check 48hrly)

medical
• methotraxate IM
• B-hCG<3000

surgical - if unstable, significant pain, can’t use methotrexate:
• laparoscopic salpingectomy (removal, if other is healthy) or salpingotomy (dissection, if other not healthy)
• anti-D if Rh-ve

Question 6

complications ectopic?

Answer 6

maternal mortality
further ectopic (esp if salpingotomy)

Question 7

what B-hCG level would you expect to see normal pregnancy on TVUS?

Answer 7

> 1500

Question 8

what causes shoulder tip pain in ectopic pregnancy?

Answer 8

diaphragmatic irritation from haemoperitoneum (seen on TVUS)

if present, don’t offer medical Tx, offer surgical

Question 9

how fast should B-hCG rise in a normal pregnancy?

Answer 9

doubles (>66 percent) every 48 hrs