Early Pregnancy Complication - Ectopic pregnancy Flashcards
What is the incidence of ectopic pregnancy?
11/1000
False +ve rate for Dx Lap for ectopic pregnancy?
5%
False -ve rate for Dx Lap for ectopic pregnancy?
3-4%
At what bHCG would you expect to see a viable intra-uterine pregnancy on TV USS?
Abdo USS
TVUS: 1500-1800
Abdo USS: 6000-6500
List the types of ectopic pregnancy starting with the most common type in descending order, extra points for %
Ampulla 55%
Isthmus 25%
Fibriale 17%
Cornual 2%
Ovarian 0.5%
Intra-abdominal 0.1%
Risk factors for ectopic pregnancy?
PID
IUCD
Sterilisation
Tubal surgery
Previous ectopic
Assisted reproduction
Mini-pill
What is the most common finding on TVUS in ectopic pregnancy? What other findings might you see?
- Inhomogenous adenxal mass - 60% - sperate from ovary ‘tubal ring’ or ‘bagel sign’
- Empty extrauterine gestational sac 20-40%
- Extra uterine embryonic pole +/- cardiac activity 15-20%
- Collection of fluid inside uterine cavity ‘pseudo sac’ 20%
- Same side as corpus luteum in 70-85% (ring of fire)
?Haemoperitoneum
What % of women with ectopic pregnancies have NO risk factors?
1/3rd
If < 6 weeks pregnanct and bleeding alone (no pain), how to manage?
Conservative - repeat pregnancy test in 7-10days, return if +ve
Safety net - heavy bleeding, pain return
If negative pregnancy test → miscarried
Who is eligible for expectant management?
- Clinically stable & pain free
- Tubal ectopic <35mm and no HB
- bHCG <1000, consider <1500
- Are able to return for follow up
How should expectant management of ectopic pregnancy be followed up?
bHCG on D 2, 4 and 7
- bHCG must drop by 15% from previous value
- Continue weekly follow up until bHCG <20
What outcomes are the same for expectant and medical management?
- Rate of future ectopic
- Risk of tubal rupture
- Need for additional Tx
- Health status, depression/anxiety
Who can have medical management of ectopic pregnancy?
- 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
How is MTX given and what follow up?
- Must be certain of Dx
- Single dose 50mg/m2
- bHCG day 4 & 7 → 15% drop, then weekly entail <15
- Can consider 2nd dose
What advise should be given when giving MTX?
What SE should you warn against?
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
Success rates of Medical Mgmt miscarriage? How many need 2nd dose of MTX?
65-95%
3-25% need second dose
Who should be offered surgical mgmt for ectopic pregnancy?
- Significant pain
- > 35mm
- Visible heart beat
- bHCG >5,000
- Unable to attend FU
- Ruptured ectopic
When should salpingotomy be considered over salpingectomy?
RF for infertility, contralateral tube damage (prev ectopic, prv PID, prv abdo surgery)
If salpingotomy is performed, how many will require further treatment?
1/5
Either repeat surgery or MTX
If saplingotomy is performed what FU should be arranged?
Recheck bHCG in 7 days, then 1 per week until negative result
If salpingectomy is perfumed what follow should be arranged?
Repeat UPT after 3 weeks, to contact if +ve
What are the recurrence rates of ectopic pregnancy?
After 2 ectopics?
18.5%
1 previous 10%
2+ 25%
If mother is Rh-ve, which mothers need anti D?
Surgical mgmt of ectopic or miscarriage
Do not give if medical mgmt miscarriage/ectopic
Miscarriage
PUL
How to manage pregnancy unknown location?
Explain, safety net TCI - pain/unwell etc
Take 2 bHCG 48 hrs apart
In PUL, if developing intrauterine pregnancy, what change would be seen between bHCG?
How to manage?
Increase in 63% or over after 48hrs
TVUS 7-14 days later, if not seen review by senior
In PUL, if pregnancy unlikely to continue, what change would be seen between bHCG?
How to manage?
Decrease in bHCG by 50% or greater
- UPT in 14 days
→ if negative no further action
→ If +ve for USS - Offer support and counselling
In PUL, if possible ectopic pregnancy, what change would be seen between bHCG?
How to manage?
Decrease less than 50%, or increase less that 63%
Clinical review
What will be see on USS for interstitial ectopic?
When do they rupture?
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)
What will be seen on USS in cervical ectopic?
Empty endometrial cavity
Gestation sac at or below levy of interval cervical Os
Absence of sliding sign
Management of cervical ectopic
High surgical failure rates, given MTX unless bHCG >10,000
If heavy bleeding hysterectomy
What is the incidence of CS scar ectopic?
1 in 2000 (increasing)
USS features of CS scar ectopic?
Empty endometrial cavity
Gestation sac located lower anterior myometrium at level of CS scar, askance sliding sing
13% misdiagnosed as intrauterine or cerival
Mgmt of CS scar ectopic prengnancy
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
Risk of recurrence with CS scar ectopic?
3.2-5%
Dx of ovarian ectopic and mgmt?
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
Mgmt heterotopic pregnancy
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
When to consider heterotypic pregnancy? Is bHCG useful in Dx?
Consider IVF
Intrauterine pregnancy but ongoing pain or persistently raised bHCG after miscarriage or TOP
bHCG not helpful
