Disorders of Early Pregnancy

Question 1

What is meant by the term ectopic pregnancy?

Answer 1

Any pregnancy that occurs outside of the uterus

Question 2

What is the most common site of an ectopic pregnancy?

Answer 2

Fallopian tube

Question 3

Where else might an ectopic pregnancy implant?

Answer 3

• ovary
• cervix
• abdomen

Question 4

What are the risk factors for an ectopic pregnancy?

Answer 4

• previous ectopic pregnancies
• PID
• previous fallopian surgery
• IUDs
• older age
• smoking

Question 5

How do ectopic pregnancies present?

Answer 5

• constant pain in the LIF or RIF
• vaginal bleeding
• missed period
• referred shoulder tip pain
• cervical motion tenderness on bimanual exam
• dizziness/fainting due to blood loss

Question 6

What are the main investigations for potential ectopics?

Answer 6

1. Urine pregnancy test
2. T48:
   Levels of BHCG taken via blood test every 48 hours; in normal pregnancy levels should double
3. TVUSS:
   May not find evidence of pregnancy if very early or BHCG levels <1500 (it is then termed pregnancy of unknown location)

Question 7

What is the management of an ectopic pregnancy?

Answer 7

1. Conservative (expectant):
Used if:
- Unruptured
- No visible heartbeat
- HCG <1500
- No pain
- Adnexal mass <35mm

Expectant management requires close follow up and monitoring

2. Medical (Methotrexate):
   - Methotrexate is highly teratogenic
   - Same criteria as expectant management except:
   - HCG must be <5000
   - Confirmed absence of intrauterine pregnancy on USS
   - Given as an intramuscular injection
   - Folic acid needs to be taken
   - Monitoring of LFTs necessary
   - Advise not to get pregnant for 3 months after
3. Surgical Management:
   - Any patient that does not meet the above criteria or:
   - Has significant pain
   - Adnexal mass >35mm
   - Visible heartbeat
   - HCG >5000
   - Managed with either laparoscopic salpingectomy or laparoscopic salpingotomy
   - May need further treatment with methotrexate
   - Treatment with Anti-D necessary in women who undergo surgical management and are rhesus negative