Early bleeding in pregnancy, Ectopic pregnancy, PUL and molar pregnancy Flashcards
What is an ectopic pregnancy?
A fertilised ovum implants outside the uterine cavity
Wha are common sites for ectopic pregnancies to implant?
- Tubal
- Ampulla
- Isthmus
- Ovary
- Abdomen
- Cervix
What is the most common site of ectopic pregnancy?
Tubal ectopic pregnancy
What are predisposing factors for ectopic pregnancy?
Anything which slow’s ovum’s passage to the uterus
- Salpingitis
- Previous surgery
- Previous ectopic
- Endometriosis
- IUCD
- POP
- Tubal ligation
What is the pathophysiology of ectopic pregnancy?
Trophoblast invades the tubal wall, weakening it and producing haemorrhage which dislodges the embryo.
If the tube does not rupture, the bleed and embryo are shed or converted into a tubal mole and absorbed
Rupture can be sudden and catastrophic, or gradual.
What are symptoms of ectopic pregnancy?
- Abdominal pain
- PV bleeding or Amenorrhoea
- Fainting/dizziness
- Diarrhoea +/- vomiting
- Shoulder tip pain
What are signs of a ectopic pregnancy?
- Normal sized uterus
- Cervical excitation +/- adnexal tenderness
- Adnexal mass - rare
- Peritonism
What is the classical presentation of ectopic pregnancy?
Sexually active woman
- Abdominal pain
- Bleeding
- Fainting
- Diarrhoea and vomiting
Can you do a vaginal examination if ectopic pregnancy is suspected?
Yes - it does not rupture ectopic pregnancies
What investigations would you consider doing in someone who you suspected had an ectopic pregnancy?
- Bedside - Pregnancy test
- Bloods - FBC, Group and save, serum progesterone, serum BHCG
- Imaging - Transvaginal Ultrasound scan
- Other - laparoscopy
Why might you do a serum progesterone in someone with suspected ectopic pregnancy?
To see if the pregnancy is failing
On serum progesterone, what might indicate that a pregnancy was failing (about to miscarry)?
<20 nmol/L
On serum progesterone, what might suggest a pregnancy was ongoing?
>60 nmol/L
What might you find on investigation of BHCG in someone with an ectopic pregnancy?
May confirm pregnancy
What is important to do when investigating using BHCG and there is no sign of intrauterine gestation?
Do serial measurement - used to differentiate between ectopic pregnancy and miscarriage
What might a steady decrease in serial BHCG values suggest?
Miscarriage (failing pregnancy)
What might you see on TVUS in someone with ectopic pregnancy?
- Location
- Adnexal mass
- Presence of free fluid
- Donut sign
What are causes of early bleeding in pregnancy?
- Miscarriage
- Ectopic pregnancy
- PUL
- Implantation bleeding
- Non-pregnancy cause - cervical polyp, GU tract trauma
- Molar pregnancy - rare
What is cervical excitation?
Pain elicited when the uterine cervix is manipulated during pelvic examination
How would you manage an ectopic pregnancy?
- Expectant
- Medical - methotrexate, anti-D for Rh -ve mother
- Surgical - laparoscopy, salpingectomy, salpingotomy
How is the decision made to adopt expectant and medical management of ectopic pregnancy?
Based on strict criteria
- Asymptomatic/mild symptoms
- HCG < 3000
- Ectopic pregnancy <3cm on scan with no FH activity
- No haemoperitoneum on TVS
- Falling HCG levels
What trend in BHCG levels would you want to see to consider managing with expectant management?
Falling HCG - take levels every 48 hrs until confirmed fall, then weekly until <15 IU
What medication would you use to medically manage someone with ectopic pregnancy?
Methotrexate
Why is methotrexate used?
Destroys trophoblastic tissue
What is important to bear in mind in terms of fertility following methotrexate treatment?
Need to be on contraception for 3 months minimum - methotrexate is teratogenic
What dose of methotrexate is given in ectopic pregnancy?
50 mg/m2 IM
What is regarded as the gold standard treatment for ectopic pregnancy?
Laparoscopy
When is a salpingectomy indicated in managing ectopic pregnancy?
- Tube is severely damaged
- Contralateral tube is healthy
- No plan for future family
- Ectopic >5cm/recurrent
What is pregnancy of unknown location?
There is no sign of intrauterine or ectopic pregnancy or retained products of conception in the presence of a positive pregnancy test, or serum hCG > 5IU
What are the main causes of the presentation of PUL?
- Early intrauterine pregnancy
- Complete miscarriage
- Failing PUL which will never be seen
- Ectopic pregnancy
- Persistent PUL
- HCG secreting tumour
How would you manage someone with pregnancy of unknown location?
- If abdo pain/haemoperitoneum - Laparoscopy
- If well - intial BHCG, repeated every 48hrs
How much should BHCG rise by in pregnancy?
Should double every 48hrs
What is a molar pregnancy?
Abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic disease. which grows into a mass in the uterus that has swollen chorionic villi
What is the diagnostic tool of choice for investigating for ectopic pregnancy?
Transvaginal ultrasound is the diagnostic tool of choice for a suspected ectopic pregnancy.
What investigations could you use to distinguish between a normal intrauterine pregnancy, an ectopic pregnancy, a miscarriage, and a molar pregnancy?
Repeat transvaginal scans, serial hCG levels, and laparoscopy
