Early pregnancy - ectopic, PUO, molar Flashcards
what is an ectopic pregnancy?
when a pregnancy is implanted outside of the uterus - most commonly in the fallopian tube
(can be entrance to fallopian tube, ovary, cervix, abdomen)
what are some risk factors for ectopic pregnancy?
previous ectopic pregnancy
previous PID
previous surgery to fallopian tubes
intrauterine devices
older age
smoking
how does an ectopic pregnancy present?
typically around 6-8 weeks gestation
missed period
constant lower abdominal pain in right or left iliac fossa
vaginal bleeding
lower abdominal or pelvic tenderness
cervical motion tenderness
what are 2 important things to ask about when suspecting an ectopic pregnancy?
dizziness or syncope
shoulder tip pain
what examinations would you do for ectopic?
abdominal exam
speculum
bimanual
what is the investigation of choice and what are the findings for ectopic?
transvaginal ultrasound scan
gestational sac containing a yolk sac or fetal pole may be seen in the fallopian tube
may see a non-specific mass in the tube - refered to as blob sign, bagel sign or tubal ring sign
mass representing a tubal ectopic pregnancy moves separately to the ovary
may see an empty uterus or fluid in the uterus
what is pregnancy of unknown location?
when woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan
how will the hCG level change in a normal uterine pregnancy?
serum hCG will roughly double every 48 hours
what is a rise of 63% after 48 hours likely to indicate and what is done following this?
intrauterine pregnancy
repeat ultrasound scan required after 1-2 weeks to confirm intrauterine pregnancy
should be visible on uss once hCG is above 1500 IU/L
when should a pregnancy be visible on uss?
once hCG is above 1500 IU/L
What does a rise of less than 63% in 48 hours indicate?
ectopic pregnancy
monitor pt
what does a fall of more than 50% indicate?
miscarriage
urinary pregnancy test should be performed after 2 weeks to conform miscarriage is complete
what are the 3 management options for ectopic pregnancy?
expectant management - natural termination
medical management - methotrexate
surgical management - salpingectomy or salpingotomy
what is the criteria for expectant management?
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1500 IU / L
what is the criteria for mangement with methotrexate?
same as expectant except
- HCG level must be <5000 IU/L
- conformed absence of intrauterine pregnancy on uss
how is an ectopic managed with methotrexate
IM injection into buttock
halts progress of pregnancy as it is teratogenic and results in spontaneous labour
advised not to get pregnant for 3 months following treatment as harmful effects can last this long
what are some common side effects of methotrexate?
vaginal bleeding
nausea and vomiting
abdominal pain
stomatitis
those who don’t meet criteria for expectant or medical management will require surgical management - most people with ectopic require surgical
what is the criteria
pain
adnexal mass >35mm
visible heart beat
HCG levels >5000 IU/L
what are the 2 options for surgical management of ectopic pregnancy?
laparoscopic salpingectomy
laparoscopic salpingotomy
(increased risk of failure to remove ectopic pregnancy with salpingotomy compared to salpingectomy)
what is a laparoscopic salpingectomy?
1st line
GA and key-hole surgery to remove affected fallopian tube and ectopic inside tube
what is a laparoscopic salpingotomy?
used in women with increased risk of infertility due to damage to the other tube
aim to avoid removing the affected fallopian tube
cut made in tube to remove ectopic and tube is closed
whats needs to be done regarding anti-rehsus d if a woman has surgical management?
anti-rhesus D prophylaxis is given to rhesus negative women having surgical mangement of ectopic pregnancy
what is a molar pregnancy? and what are the 2 types?
hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus
2 types: complete mole and partial mole
what is a complete mole?
occurs when 2 sperm cells fertilise an ovum that contains no genetic material
sperm then combine genetic material and cells start to divide and grow into a tumour - complete mole
NO fetal material
what is a partial mole?
occurs when 2 sperm cells fertilise a normal ovum (containing genetic material) at the same time
new cell now has 3 sets of chromosomes
cell divides and multiplies into a tumour called partial mole
SOME fetal material may form
what are some signs that may indicate molar pregnancy?
more severe morning sickness
vaginal bleeding
increased enlargement of the uterus
abnormally high hCG
thyrotoxicosis
what is seen on uss of a molar pregnancy?
snowstorm appearance
how is a molar pregnancy managed?
evacuation of the uterus TO remove the mole
products of conception need to be sent for histological examination to confirm molar pregnancy
pt referred to gestational trophoblastoc disease centre for follow up
hCG levels monitored until they return to normal
can metastasise and may need systemic chemotherapy
