Bleeding in early pregnancy: Ectopic pregnancies

Question 3

Causes of bleeding in 1st trimester

Answer 3

1. Intrauterine pregnancies
   - Blighted ovum
   - Threatened miscarriage
   - Inevitable miscarriage
   - Incomplete miscarriage
   - Complete miscarriage
   - Missed miscarriage
   - Trophoblastic miscarriage: molar pregnancy, partial mole and choriocarcinoma
2. Ectopic pregnancies
3. Non-pregnancy causes
   - Cervical polyp, cancer, ectropion
   - Infection

Question 4

What is ectopic pregnancy?

Answer 4

Presence of pregnancy outside uterus
- leading cause of pregnancy-related death in 1st trimester

Question 5

Sites of ectopic pregnancies

Answer 5

1. Fallopian tube
   - Ampullary segment**
   - Isthmic segment
   - Fimbrial end
   - Interstitial
2. Ovarian
3. Abdominal
4. Cervical

Question 6

Risk factors for ectopic pregnancy

Answer 6

Previous pelvic inflammation
- Pelvic inflammatory disease
- Endometriosis
- Previous surgery
IUCD use
Assisted reproduction
Smoking
Previous ectopic pregnancy

Question 7

Symptoms of ectopic pregnancy

Answer 7

Severe abdominal pain, tenderness
Vaginal bleeding

Question 8

Pelvic examination of ectopic pregnancy

Answer 8

Acute rupture of ectopic pregnancy:
Hemodynamically unstable
Distended abdomen + Guarding + Rebound tenderness
Cervix os CLOSED
Cervical motion tenderness
Uterus small
Adnexal tenderness

Question 9

Principles for possible ectopic workup

Answer 9

• hCG level > 1500iu/L: if there is intrauterine pregnancy -> should be seen on TVUS
• hCG doubles every 48h for a normal intrauterine pregnancy
• once an intrauterine pregnancy is visualised, risk of ectopic is very low

Question 10

Patient presents with vaginal bleeding, cramping and UPT is +ve, what is the immediate investigation to be done?

Answer 10

Ultrasound possible outcomes:
- intrauterine pregnancy
- ectopic pregnancy
- abnormal IUP (miscarriage)
- non-diagnostic (early pregnancy vs miscarriage vs ectopic pregnancy)

Question 11

In a non-diagnostic U/S, what test can be used as a discriminatory level to detect an ectopic pregnancy?

Answer 11

Serum B-hCG concentration (1500)

Question 12

If hCG > 1500IU/L

Answer 12

Consider repeat scan to look for IUP or extrauterine pregnancy

Question 13

If hCG < 1500

Answer 13

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

Question 14

Ultrasound features of ectopic pregnancy

Answer 14

• 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

Question 15

Management of ectopic pregnancy

Answer 15

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

Question 16

Indications to start with IM MTX

Answer 16

• Pre-treatment plasma bhCG < 5000IU/L*
• Absence of yolk sac/fetal heart
• Adnexal mass <3.5cm*
• No free fluid in pouch of Douglas
• Compliance to regular follow-up to trend bhCG until normal*
• Hemodynamically stable

Question 17

Contraindications to methotrexate

Answer 17

Breastfeeding
Immunodeficiency
PUD
Active pulmonary disease
Renal/ Hepatic Insufficiency
Coexisting viable intrauterine pregnancy
Hypersensitivity/ drug allergy
Hemodynamically unstable