Clinical: Ectopic Preggers

Question 1

Define Ectopic Pregs.

Answer 1

A Gestation that Implants Outside the Endometrial Cavity.

Question 2

Why is ectopic pregnancy important to find and treat early ?

Answer 2

the fourth leading cause of maternal mortality overall.

It is the leading cause of maternal mortality in the first trimester.

Question 3

Why has ectopic pregnancy quadrupled in since 1970’s ?

Answer 3

Increase in Pelvic Inflammatory Disease (Rates increase 6-10x)

Question 4

What pathogen is most often associated with Pelvic Inflammatory Disease and has had a role in the increase of Ectopic Pregnancy ?

Answer 4

Chlamydia

Question 5

What is the most important risk factor for EP ?

Answer 5

Prior PID (Prior EP is also highly correlated)

Question 6

What mechanical etiologies can lead to EP ?

Answer 6

Previous Tubal Surgery
History of Infertility and Reproductive Therapy
IUD (not so much any more)

Question 7

What is the most common site of EP ?

Answer 7

Uterine Tube (Ampulla is most common site )

Question 8

When will most ectopic pregnancies present to you in clinic ? Why ?

Answer 8

7 Weeks
Most EP’s are in the uterine tube. By 7 weeks the growth in the tube leads to immense pain and possible rupture –> Doctors visit !

Question 9

Classic Triad of Ectopic Pregnancy:

Answer 9

1. Abdominal/Pelvic Pain (90%)
2. Vaginal Bleeding (50-80%)
3. Amenorrhea (75-90%)

Question 10

Typically patients present with abdominal pain and distension as well as symptoms of hypovolemia. What are the symptoms of hypovolemia ?

Answer 10

Tachycardia, Diaphoresis,Orthostatic Blood Pressure Changes.

Question 11

Will most patients with EP present with fever ?

Answer 11

No most are afebrile

Question 12

What percentage of patients with EP will present with an adnexal mass ?

Answer 12

50% (kind of a crap shoot)

In half of these the mass is contralateral
and represents the corpus luteum.

Question 13

In all patients in which you think there might be an EP, you have to assume ..

Answer 13

PREGNANT !

Question 14

What 3 modalities are used to diagnose EP

Answer 14

Serum hCG
Pelvic Ultrasound
Serum Progesterone

Question 15

What level of hCG must be present to confirm a ‘viable’ pregnancy ?

Answer 15

1200 (although the other prof said 1500)

Question 16

In the early stages of pregnancy, what would you like to see the hCG levels do every 48 hrs to quantify a good prognosis for viability of the pregnancy ?

Answer 16

Double

Question 17

What is ultrasound used for in the diagnosis of EP ?

Answer 17

looking for presence or absence of uterine pregnancy

Preferably endovaginal which can detect pregnancy post 5 weeks gestation.

You may be able to see an ectopic pregnancy on US as well

Question 18

What level of progesterone is indicative of Inter Uterine Pregnancy ?

Answer 18

> 25ng/mL

Question 19

Suppose you obtain a hCG of 1000 and a negative ultrasound done at 5 weeks. Is this enough to diagnose an ectopic pregnancy ?

Answer 19

NO
Even though there is no sign on pregnancy on US you will still need a level of hCG greater than 1200 to definitively diagnose an EP

Question 20

What is Culdocentesis ?

Answer 20

Put a needle through the culdesac (pouch of douglas).If blood clots its vascular, if not its probably ectopic).

Not used much

Question 21

What is the GOLD STANDARD for EP diagnosis ?

Answer 21

hCG and Endovaginal US

Question 22

What minimally invasive procedure can you use to diagnose an EP ?

Answer 22

laproscopic examination

Question 23

What medical EP treatment utilizes the blocking of Dihydrofolate Reductase leading to inhibition of pregnancy progression ?

Answer 23

Methotrexate (Folinic Acid Antagonist)

Question 24

For which patients is methotrexate indicated ?

Answer 24

Mass <3.5cm
Not Ruptured
No Fetal Cardiac Motion
Patient Desires Future Fertility
No Contraindications

Question 25

What are some common contraindications to methotrexate use ?

Answer 25

liver disease,
immunodeficiency
known sensitivity

Question 26

What is methotrexate dosing based on ?

Answer 26

Surface area (50 mg/m^20

Question 27

How do you monitor to see if methotrexate has worked in limiting EP ?

Answer 27

Serial S- hCG . Should eventually lower to zero

hCG will increase in the first 4 days but should begin to decline by day 7

Question 28

What should you do if initial methotrexate dosing fails ?

Answer 28

Give a second dose or consider surgery

Question 29

Laparoscopy

Answer 29

Using a scope to with a small incision to visualize target (in this case a tubal EP)

Question 30

Laparotomy

Answer 30

Use of a much larger incision than laproscopy (often thought of as exploratory surgery)

Question 31

Salpingostomy

Answer 31

Creating a cut in the fallopian tube and then excising the contents while leaving the fallopian tube intact. You do not close this with sutures as the healing process will harm the tube

Question 32

Salpingectomy

Answer 32

Removal of the fallopian tube with tubal ligation
Can be total or subtotal.

Will require ligating with either suture or cauterization

Question 33

What should you treat Rh- mothers with prior to EP surgical removal ?

Answer 33

Rhogam

Question 34

What should be done post surgery to monitor effectiveness of treatment ?

Answer 34

Serial S-hCG levels

Question 35

What must you consult after the procedure to be sure of diagnosis and prospected outcome ?

Answer 35

Pathology Report

Question 36

What should patients avoid for 3-6 months post EP removal ?

Answer 36

Pregnancy

The damage to the tube could lead to another EP

Question 37

Relative future risk if there is a history of EP ?

Answer 37

15-50%

Question 38

Altough the incidence of EP has 4x. Why has mortality decreased ?

Answer 38

High Index of Suspicion and early detection.