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MRCOG Early Pregnancy Part 2 Hay > Early Pregnancy Complication - Ectopic pregnancy > Flashcards

Early Pregnancy Complication - Ectopic pregnancy Flashcards

1
Q

What is the incidence of ectopic pregnancy?

A

11/1000

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2
Q

False +ve rate for Dx Lap for ectopic pregnancy?

A

5%

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3
Q

False -ve rate for Dx Lap for ectopic pregnancy?

A

3-4%

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4
Q

At what bHCG would you expect to see a viable intra-uterine pregnancy on TV USS?

Abdo USS

A

TVUS: 1500-1800
Abdo USS: 6000-6500

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5
Q

List the types of ectopic pregnancy starting with the most common type in descending order, extra points for %

A

Ampulla 55%
Isthmus 25%
Fibriale 17%
Cornual 2%
Ovarian 0.5%
Intra-abdominal 0.1%

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6
Q

Risk factors for ectopic pregnancy?

A

PID
IUCD
Sterilisation
Tubal surgery
Previous ectopic
Assisted reproduction
Mini-pill

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7
Q

What is the most common finding on TVUS in ectopic pregnancy? What other findings might you see?

A
  1. Inhomogenous adenxal mass - 60% - sperate from ovary ‘tubal ring’ or ‘bagel sign’
  2. Empty extrauterine gestational sac 20-40%
  3. Extra uterine embryonic pole +/- cardiac activity 15-20%
  4. Collection of fluid inside uterine cavity ‘pseudo sac’ 20%
  5. Same side as corpus luteum in 70-85% (ring of fire)

?Haemoperitoneum

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8
Q

What % of women with ectopic pregnancies have NO risk factors?

A

1/3rd

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9
Q

If < 6 weeks pregnanct and bleeding alone (no pain), how to manage?

A

Conservative - repeat pregnancy test in 7-10days, return if +ve
Safety net - heavy bleeding, pain return
If negative pregnancy test → miscarried

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10
Q

Who is eligible for expectant management?

A
  1. Clinically stable & pain free
  2. Tubal ectopic <35mm and no HB
  3. bHCG <1000, consider <1500
  4. Are able to return for follow up
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11
Q

How should expectant management of ectopic pregnancy be followed up?

A

bHCG on D 2, 4 and 7

  • bHCG must drop by 15% from previous value
  • Continue weekly follow up until bHCG <20
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12
Q

What outcomes are the same for expectant and medical management?

A
  • Rate of future ectopic
  • Risk of tubal rupture
  • Need for additional Tx
  • Health status, depression/anxiety
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13
Q

Who can have medical management of ectopic pregnancy?

A
  • No significant pain
  • Unruptured tubal ectopic <35mm, no HB
  • bHCG <1500, consider upto 5000
  • No intrauterine pregnancy
  • Can return to follow up
  • No CI to MTX
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14
Q

How is MTX given and what follow up?

A
  • Must be certain of Dx
  • Single dose 50mg/m2
  • bHCG day 4 & 7 → 15% drop, then weekly entail <15
  • Can consider 2nd dose
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15
Q

What advise should be given when giving MTX?
What SE should you warn against?

A

Must avoid ETOH & folate containing vitamins
Avoid sexual intercourse during Tx
Should use reliable contraction for 3 months after (teratogenic)
Drink plenty of fluids

Adverse - marrow suppression, pulmonary fibrosis, pneumonitis, liver cirrhosis, renal failure, gastric ulcers, flatulance, mildly raised LFT

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16
Q

Success rates of Medical Mgmt miscarriage? How many need 2nd dose of MTX?

A

65-95%
3-25% need second dose

17
Q

Who should be offered surgical mgmt for ectopic pregnancy?

A
  • Significant pain
  • > 35mm
  • Visible heart beat
  • bHCG >5,000
  • Unable to attend FU
  • Ruptured ectopic
18
Q

When should salpingotomy be considered over salpingectomy?

A

RF for infertility, contralateral tube damage (prev ectopic, prv PID, prv abdo surgery)

19
Q

If salpingotomy is performed, how many will require further treatment?

A

1/5
Either repeat surgery or MTX

20
Q

If saplingotomy is performed what FU should be arranged?

A

Recheck bHCG in 7 days, then 1 per week until negative result

21
Q

If salpingectomy is perfumed what follow should be arranged?

A

Repeat UPT after 3 weeks, to contact if +ve

22
Q

What are the recurrence rates of ectopic pregnancy?

After 2 ectopics?

A

18.5%

1 previous 10%
2+ 25%

23
Q

If mother is Rh-ve, which mothers need anti D?

A

Surgical mgmt of ectopic or miscarriage

Do not give if medical mgmt miscarriage/ectopic
Miscarriage
PUL

24
Q

How to manage pregnancy unknown location?

A

Explain, safety net TCI - pain/unwell etc

Take 2 bHCG 48 hrs apart

25
Q

In PUL, if developing intrauterine pregnancy, what change would be seen between bHCG?
How to manage?

A

Increase in 63% or over after 48hrs
TVUS 7-14 days later, if not seen review by senior

26
Q

In PUL, if pregnancy unlikely to continue, what change would be seen between bHCG?
How to manage?

A

Decrease in bHCG by 50% or greater

  • UPT in 14 days
    → if negative no further action
    → If +ve for USS
  • Offer support and counselling
27
Q

In PUL, if possible ectopic pregnancy, what change would be seen between bHCG?
How to manage?

A

Decrease less than 50%, or increase less that 63%

Clinical review

28
Q

What will be see on USS for interstitial ectopic?

When do they rupture?

A

Empty uterine cavity
Product in interstitial part of tube, <5mm myometrium in all imaging planes
Interstitial line sign

8-16 weeks, very vascular (ovarian and uterine blood supply)

29
Q

What will be seen on USS in cervical ectopic?

A

Empty endometrial cavity
Gestation sac at or below levy of interval cervical Os
Absence of sliding sign

30
Q

Management of cervical ectopic

A

High surgical failure rates, given MTX unless bHCG >10,000
If heavy bleeding hysterectomy

31
Q

What is the incidence of CS scar ectopic?

A

1 in 2000 (increasing)

32
Q

USS features of CS scar ectopic?

A

Empty endometrial cavity
Gestation sac located lower anterior myometrium at level of CS scar, askance sliding sing

13% misdiagnosed as intrauterine or cerival

33
Q

Mgmt of CS scar ectopic prengnancy

A

Medical - USS guidance injection into gestation sac of MTX. Consider is <8/40 and bHCG <5000, stable

Surgical - evacuation of pregnancy (suction or hysteroscopy) or Lap/open excision

Expectant only if non viable pregnancy or only partially implanted.

High risk of maternal morbidty/hysterectomy in 2nd trimester

34
Q

Risk of recurrence with CS scar ectopic?

A

3.2-5%

35
Q

Dx of ovarian ectopic and mgmt?

A

Non specific on USS - negative sliding sign, corpus separate. Dx confirmed surgically.

Lap surgical options preferred.
Can give MTX if surgical high risk, but 40% failure rate

36
Q

Mgmt heterotopic pregnancy

A

Must consider intrauterine prengnancy
Only MXT if not viable intauterine or woman does not wish to continue pregnancy
Local injection with KCL to hyperosmolar glucose
Surgical if unstable

37
Q

When to consider heterotypic pregnancy? Is bHCG useful in Dx?

A

Consider IVF
Intrauterine pregnancy but ongoing pain or persistently raised bHCG after miscarriage or TOP
bHCG not helpful

MRCOG Early Pregnancy Part 2 Hay (8 decks)

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