Ectopic

Question 1

Name the four sites of the fallopian tube and where ectopics commonly happen, and where they can rupture commonly

Answer 1

Fimbriae
Infundibulum
Ampulla - 73 percent of ectopics
Isthmus - common site of rupture

Question 2

What do you call it when someone has an intrauterine and extrauterine pregnancy at the same time?

Answer 2

Heterotropic pregnancy

Question 3

What three things are important for the migration of the egg to the uterus?

Answer 3

Cilia motion
Tubal fluid
Tubal peristalsis

Question 4

RF for ectopic

Answer 4

Damage to fallopian tubes from PID, STI, tubal surgery, chronic salpingitis, salpingitis isthmica nodosa

Previous ectopics

IUS/IUD
SMOKING

also endometriosis
progesterone contraceptive - slows down cilia

Question 5

Signs and symptoms

Answer 5

Lower abdominal pain
Bleeding
Shoulder tip pain if rupture has caused haemoperitoneum and peritonitis
Collapse, dizziness, amenorrhoea, D and V

Question 6

Investigations

Answer 6

A to E approach
Basic obs
Abdo and pelvic exam
Bimanual speculum
Urine/serum pregnancy test
Bloods - beta HCG, FBC, U and E (kidney stones), group and save, CRP (appendicitis)
TVUSSA

Question 7

What would be seen on TVUSS/bimanual?

Answer 7

Adnexal mass on TVUSS
Bimanual - adnexal tenderness

Question 8

Differentials

Answer 8

TINCANBEDS

T - ovarian torsion
I - appendicitis, PID
N - molar preganncy
C
A
N
B
E - kidney stones
D
S - ovarian torsion, kidney stones

PID
Miscarriage
Molar pregnancy
Ovarian torsion

Question 9

How would an ectopic in the tubes present differently from if they were in the ovaries?

Answer 9

If in tubes - smaller space therefore presents within 6-8 weeks of conception

If in ovary, more space to grow therefore would present a lot later

Question 10

How should beta HCG increase in a normal pregnancy?

Answer 10

Double if normal in 48 hours

Question 11

Management if haemodynamically unstable

Answer 11

A to E approach
Oxygen
Two wide bore cannula
Fluid with 0.9 percent sodium chloride

Surgery - emergency laparotomy

Question 12

What does bHCG do?

Answer 12

Takes on the role of LH, so it stimulates the corpus luteum to produce progesterone

Question 13

Conservative management of an ectopic + what percentage of people have spontaneous resolutions of their ectopic?

Answer 13

Wait and watch
Repeat bHCG levels in TWO days
If no change and hasn’t declined, go for medical option
‘Your body naturally resolves the pregnancy’

3/4 people

Question 14

Medical management + how does the drug work

Answer 14

IM Methotrexate - make sure U and E and LFT measured

Methotrexate = Folic acid antagonist so it inhibits DNA synthesis

bHCG levels at day 4 and day 7

Day 4 - bhcg levels rise
Day 7 - they start to fall

Then weekly until negative result is obtained

If it doesn’t decrease, surgery

Question 15

Surgical management options + what they are + what is preferred

Answer 15

Laparoscopy = key hole
Laparotomy = reserved for if there is rupture

Laparoscopy types = salpingectomy and salpingotomy

Salpingectomy = resection of entire fallopian tube (preferred if other fallopian tube is okay)
SalpingOtomy = resection of ONLY the ectopic

Question 16

What percentage of people get pregnant after a salpingectomy?

Answer 16

2/3 of people get preg after 18m

Question 17

How would you explain why we prefer salpingectomies to salpingotomies

Answer 17

If there is any damage to a fallopian tube, it increases the risk of another ectopic.
So actually there is no difference in the chance of getting another ectopic between salpingotomy and salpingectomy.

Question 18

Acronym for deciding the management option

Answer 18

Some pregancies have horrible outcomes

Size <35
Pain severity
bHCG <1000 for cons, <1500 for medical and >1500 for surgical
foetal Heart beat (if present, surgical)
Others - hemoperitoneum, Haemodynamic stability etc

Question 19

When is methotrexate contraindicated

Answer 19

Immunosuppression
Breastfeeding
IU preg
Liver, renal or haem disorder

Question 20

SE of methotrexate

Answer 20

N and V
Stomatitis

Question 21

When would you give anti-D prophylaxis?

Answer 21

Give 250 IU ASAP to all women who are RhD negative after surgery

Question 22

What percentage of people having salpingOtomy need methotrexate?

Answer 22

1/5

Question 23

F/U after salpingectomy

Answer 23

Urine preg at 3 week

Question 24

F/U after salpingotomy

Answer 24

serum b HCG at 1 week
then weekly until negative

Question 25

Advice when giving methotrex

Answer 25

Don’t get preg for 3months
Avoid EtOH and Sun
Pain and diarrhoea settlse with paracetamol
You may need to stay overnight and then return to the clinic later