Bleeding in early pregnancy: Ectopic pregnancies Flashcards
Causes of bleeding in 1st trimester
- Intrauterine pregnancies
- Blighted ovum
- Threatened miscarriage
- Inevitable miscarriage
- Incomplete miscarriage
- Complete miscarriage
- Missed miscarriage
- Trophoblastic miscarriage: molar pregnancy, partial mole and choriocarcinoma - Ectopic pregnancies
- Non-pregnancy causes
- Cervical polyp, cancer, ectropion
- Infection
What is ectopic pregnancy?
Presence of pregnancy outside uterus
- leading cause of pregnancy-related death in 1st trimester
Sites of ectopic pregnancies
- Fallopian tube
- Ampullary segment**
- Isthmic segment
- Fimbrial end
- Interstitial - Ovarian
- Abdominal
- Cervical
Risk factors for ectopic pregnancy
Previous pelvic inflammation
- Pelvic inflammatory disease
- Endometriosis
- Previous surgery
IUCD use
Assisted reproduction
Smoking
Previous ectopic pregnancy
Tubal ligation (sterilisation surgery)
Symptoms of ectopic pregnancy
Severe abdominal pain, tenderness
Vaginal bleeding
Pelvic examination of ectopic pregnancy
Acute rupture of ectopic pregnancy:
Hemodynamically unstable
Distended abdomen + Guarding + Rebound tenderness
Cervix os CLOSED
Cervical excitation
Adnexal tenderness
Principles for possible ectopic workup
- hCG level > 1500iu/L: if there is intrauterine pregnancy -> should be seen on TVUS (if no IUP seen, consider ectopic +++)
- hCG doubles every 48h for a normal intrauterine pregnancy
- once an intrauterine pregnancy is visualised, risk of ectopic is very low
Patient presents with vaginal bleeding, cramping and UPT is +ve, what is the immediate investigation to be done?
TV Ultrasound possible outcomes:
- intrauterine pregnancy
- ectopic pregnancy
- abnormal IUP (miscarriage)
- non-diagnostic (early pregnancy vs miscarriage vs ectopic pregnancy)
In a non-diagnostic U/S, what test can be used as a discriminatory level to detect an ectopic pregnancy?
Serum B-hCG concentration (1500)
If hCG > 1500IU/L
IUP must be seen if present, if not its ectopic ++
Consider repeat scan to look for IUP or extrauterine pregnancy
If hCG < 1500
Perform serial hCG in 48h
- If normal rise (x2): U/S when hCG > 1500 to look for IUP
- If abnormal rise less than double: Ectopic pregnancy
- If normal (ie. negative result): Miscarriage
Ultrasound features of ectopic pregnancy
- Empty uterus and an adnexal mass
- Fluid in the pouch of Douglas
- Presence of an ectopic gestational sac
- Pseudo-gestational sac in the uterus
- ‘Double ring’ in adnexa
Management of ectopic pregnancy
Medical
- IM Methotrexate
- If hCG does not decrease, consider 2nd try of MTX vs surgery
Surgical
- Healthy contralateral tube: Laparoscopy Salpingectomy
- Diseased contralateral tube: Laparoscopy Salpingostomy followed by weekly bhCG until negative
NOTE: salpinGECTOMY is the GOLD standard for ruptured ectopic pregnancy regardless
Indications to start with IM MTX
- Pre-treatment plasma bhCG < 5000IU/L*
- Absence of yolk sac/fetal heart activity
- Adnexal mass <3.5cm*
- No free fluid in pouch of Douglas
- Compliance to regular follow-up to trend bhCG until normal*
- Hemodynamically stable
Contraindications to methotrexate
Breastfeeding
Coexisting viable intrauterine pregnancy
Hypersensitivity/ drug allergy
Hemodynamically unstable
Ruptured ectopic pregnancy
Large ectopic size
Fetal cardiac activity
Immunodeficiency
PUD
Active pulmonary disease
Renal/ Hepatic Insufficiency
