Early Pregnancy Flashcards
Define ectopic pregnancy
Any pregnancy which is implanted outside of the uterine cavity
Most common site is ampulla and isthmus of fallopian tube
Risk factors for ectopic pregnancy
PMH - previous ectopic - PID - endometriosis SH - smoking Contraception - IUD or IUS - POP - tubal ligation or occlusion Iatrogenic - pelvic surgery - assisted reproduction
Clinical features of ectopic pregnancy
Lower abdominal/pelvic pain +/- vaginal bleeding
Shoulder tip pain
Vaginal discharge - brown in colour
Abdominal tenderness, cervical excitation and/or adnexal tenderness
May be signs of shock if ruptured
What causes vaginal bleeding in ectopic pregnancy?
Decidual breakdown in the uterine cavity due to suboptimal β-HCG levels
Bleeding from a ruptured ectopic pregnancy is usually intra-abdominal, not vaginal
Differential diagnosis of ectopic pregnancy
Miscarriage Ovarian cyst accident - rupture, haemorrhage or torsion Acute PID UTI Appendicitis Diverticulitis
Investigations for ectopic pregnancy
Pregnancy test - urine beta-hCG
Pelvic USS - look for intrauterine by TA and TV
If unable to find pregnancy on USS but serum hCG positive = pregnancy of unknown location
Criteria for ectopic pregnancy
If the initial β-HCG level is >1500 iU and there is no intrauterine pregnancy on transvaginal ultrasound
- then this should be considered an ectopic pregnancy until proven otherwise
-diagnostic laparoscopy should be offered
If the initial β-HCG level is <1500 iU and the patient is stable, a further blood test can be taken 48 hours later:
- In a viable pregnancy, hCG level would be expected to double every 48 hours
- In a miscarriage, hCG level would be expected to halve every 48 hours
- Where the increase or drop in the rate of change is outside these limits, an ectopic pregnancy cannot be excluded and the patient should be managed accordingly
Differentials of pregnancy of unknown location
Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy
Medical management of ectopic pregnancy
IM Methotrexate
- anti-folate cytotoxic agent that disrupts folate dependent cell division of developing foetus
Serum b-hCG level monitored regularly to ensure the level is declining - >15% in day 4-5
- if doesn’t decline a repeat dose is administered
Advantages/disadvantages of medical management of ectopic pregnancy
Advantages
- avoid complications of surgical management
- patient can go home after injection
Disadvantages
- side effects of methotrexate - abdo pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis - contraception for 3-6 months
- treatment can fail -> surgical intervention
Factors affecting type of management of ectopic pregnancy
Medical management - stable with well controlled pain - beta-hCG levels < 1500 iU/ml - unruptured without visible heartbeat - patient should have access to 24 hr gynaecology services Surgical management - severe pain - serum hCG > 5000 - adnexal mass > 34 mm - foetal heartbeat visible on scan Conservative/expectant - clinically stable and pain free - adnexal mass less than 34mm and no FH - beta hCG < 1000
Surgical management of ectopic pregnancy
Surgical removal of ectopic
- laparoscopic salpingotomy/salpingectomy
HCG follow up required until level reaches < 5 to ensure no residual trophoblast
All rhesus negative women should be offered anti-D propohylaxis
Advantages/disadvantages of surgical management of ectopic
Advantages - reassurance about when definitive treatment provided - high success rate Disadvantages - GA risk - risk of damage to neighbouring structures - bladder, bowel, ureters - DVT/PE - haemorrhage - infection - risk of failure with salpingotomy
Conservative management of ectopic pregnancy
Watchful waiting of stable patient while allowing ectopic to resolve naturally
Serum b-hCG monitored every 48 hours to ensure falling by equal to or greater than 50% until reaches < 5
The patient should have access to 24-hour gynaecology services and informed of the symptoms of rupture
Advantages/disadvantages of conservative management of ectopic pregnacy
Advantages
- avoid risk of medical and surgical management
- can be done at home
Disadvantages
- failure or complications -> medical or surgical management
- rupture of ectopic
Complications of untreated ectopic pregnancy
Fallopian tube rupture
- blood loss -> hypovolaemic shock -> organ failure and death
Define miscarriage
Loss of pregnancy at less than 24 weeks gestation
- occur in 20-25% of pregnancies
Risk factors for miscarriage
Maternal age > 30 Previous miscarriage Obesity Chromosomal abnormalities Smoking Uterine abnormalities Previous uterine surgery Anti-phospholipid syndrome Coagulopathies
Clinical features of a miscarriage
Vaginal bleeding - may include passing clots and products of conception
Excessive bleeding can lead to haemodynamic instability -> dizziness, pallor and SOB
Examination findings of miscarriage
Haemodynamically instability - pallor, tachycardia, tachypnoea, hypotension
Abdominal examination - abdominal distention with areas of tenderness
Speculum examination - assess diameter of cervical os and observe for any products of conception of bleeding
Bimanual examination - uterine tenderness or adnexal masses or collections
Differential diagnosis of miscarriage
Ectopic pregnancy
Hydatidiform mole
Cervical/uterine malignancy
Investigations for suspected miscarriage
Imaging - TV USS - small CRL or lack of foetal heartbeat Blood tests - serum bHCG - FBC - blood group and rhesus status - triple swabs and CRP if pyrexial
