Chapter 19: First Trimester Bleeding: Ectopic Pregnancy and Abortion Flashcards
How often does an ectopic happen and where is the most common site?
Ectopic Pregnancy – Blastocyst implantation anywhere other than uterus. 1.5% of reported pregnancies
i) 98% in fallopian tube with 80% in the ampulla
ii) Threat reduced from the past due to transvaginal US and b-hCG testing
Symptoms of an Ectopic
Symptoms
i) Amenorrhea followed by vaginal bleeding and abdominal pain on the affected side
ii) Disturbing findings: Shoulder pain worsened by inspiration (could indicate bleeding into abdomen irritating diaphragm and phrenic nerves)
iii) Passing decidual cast by pregnany patient with no placental villi on pathology means ectopic pregnancy is likely
Causes of Tubal ectopics
(1) Inflammation against tubes stopping normal progress of conception
(a) Salpingitis, salpingitis isthmica nodosa, acute chlamydial infection causing intraluminal inflammation and subsequent fibrin deposition with tubal scarring
(i) Even with negative chlamydial cultures, persistent chlamydial antigens can lead to a hypersensitivity reaction later on (7-14 days) (unlike N. Gonorrhea whose endotoxin causes rapid clinical onset)
(b) Other risk factors: Smoking, prior ectopic, prior tubal surgery, diethylstilbesterol exposure, and advanced age
Outcomes of untreated tubal ectopics
(1) Tubal abortion: Products of conception expelled from fimbriae, which can lead to implantation in the abdomen
(2) Tubal rupture: Hemorrhage leading to surgery
Ruptured ectopic presentation
(1) ¾ of women will have tenderness in pelvis and abdomen, aggravated by cervical manipulation
(2) Pelvic mass with fullness posterolateral to the uterus can be palpated in 20% of women
(a) Soft and elastic initially, harder with hemorrhage
(3) Consider avoiding pelvic examination due to possibility of iatrogenic rupture
(4) Fever may result in response to intraperitoneal blood. 38C indicates infectious cause
(5) Adnexal mass in 1/3 of patients
First trimester bleeding does not always mean ectopic. What must you also consider:
i) Missed abortion, placental polyp, hemorrhage corpus luteal cyst, appendicitis, renal calculus
(1) 20% of normal pregnancies have early bleeding
What are the ways to test for ectopic:
- TVS
- Serial serum bhCG
- Serum progesterone test
- Endometrial curettage
- Culdocentesis
- Laparoscopy
- Pregnancy test
TVS findings with an ectopic
(1) Identify location of ectopic (gestational sac visible at 4.5-5 weeks from LMP
(2) Yolk sac at 5-6 weeks
(3) Fetal pole with heart beat at 5.5-6 weeks
(a) Pseudogestational sac: Fluid collection that mimics appearance of gestation, caused by sloughing of decidua in midline uterine cavity, whereas the normal sac is eccentrically located
How can serial b-hCGs help us with an ectopic?
Serial serum b-hCG (as early as 5 days
(1) Within 60-80 days of last menses, 53% or more increase in b-hCG should occur every 48 hours. Less than this could be ectopic or otherwise abnormal pregnancy
(a) 15% of normal pregnancies can also have this delayed rise in b-hCG
(b) 17% of ectopics have normal increase in b-hCG
How can a serum progesterone test help us with an ectopic?
Serum progesterone test – Doesn’t change between 5-10 weeks, so one value is good for diagnosis
(1) 20: Sensitivity >90% with 40% specificity that there is a healthy pregnancy
Ectopic endometrial curettage findings
Endometrial curettage
(1) Curettage of endometrial cavity, big risk for intrauterine pregnancy
(2) Arias-Stella reaction – Hypersecretory endometrium of pregnancy seen on histology for any pregnancy
How does a culdocentesis help us with ectopic?
(1) Can identify blood in the peritoneal cavity
(2) 18G needle inserted posterior to the cervix between uterosacral ligaments and into cul-de-sac of peritoneal cavity
(3) Aspiration of non-clotting blood = hemoperitoneum
(4) Purulence = infection
Laparoscopy for ectopic:
(1) Look at it! Only 2-5% missed diagnosis
(a) Hematosalpinx – Blood clot in fallopian tube mistaken as unruptured ectopic or tubal abortion
Pregnancy test for ectopic?
Pregnancy test (positive in 90% of ectopics and can be done as early as 14 days)
What is the first medical management for ectopic
Methotrexate – Folic acid antagonist that inhibits binding of dihydrofolate reductase, reducing amount of active intracellular metabolite folinic acid, stopping the growth of rapidly dividing placental, embryonic, and fetal cells
Contraindications for methotrexate
(i) Absolute
1. Brestfeeding, evidence of immunodeficiency, alcoholism, liver disease, blood dyscrasias (anemia, thrombocytopenia, leukopenia), pulmonary disease, PUD, liver/kidney/hematologic dysfunction
(ii) Relative
1. Gestational sac > 3.5 cm, embryonic cardiac motion
Why is it important to check b-hCG for methotrexate use
Initial serum b-hCG 15,000 = 68% success rate
