Ectopic Flashcards
Definition
Pregnancy outside the uterine cavity
Most common site
Fallopian tube–>ampulla
Most common cause of T1 pregnancy related death
Ectopic pregnancy
Biggest risk factor for ectopic
Previous ectopic
Risk factors
Previous ectopic PID STI's Pelvic/abdominal surgery IUD Infertility treatment Smoking
Epidemiology
2% pregnancies
More common in >35 yo
Symptoms
Abdominal pain
Amenorrhea
Vaginal bleeding
History
Abdominal pain, amenorrhea, vaginal bleeding
Risk factors
Evidence of rupture->shock, peritonitis
Shoulder tip pain, urge to deficate
Examination
General–>evidence of hemodynamic instability (rupture), hypotensive, orthostatic, tachyC, pallor
Pelvic examination->tender, mass, blood in vaginal vault
Cervical motion tenderness
Palpable adnexal mass
Rebound tenderness
Investigations
FBC
bHCG
TVUS/Pelvic U/S
When can a gestational sac be seen on TVUS (bHCG level)
serum hCG levels above 1500-2000 U/L (1500-2000 mU/mL) with a TVUS (higher levels for transabdominal ultrasound).
What to do if bHCG levels below which you can see a gestational sac
If the initial serum hCG levels are below these discriminatory levels, a repeat ultrasound in 1 week or serial serum hCG levels can be requested.
Medical management Indications Contraindications Caution Regimen Followup
I: hemodynamically stable, unrupture, no signs of active bleeding, low HCG
CI: Geographic isolation, allergy, potential non-compliance
Caution: Baseline bHCG >5000, ectopic >3cm on TVS, presence of F. heart motion
R: Methotrexate
F/U: weekly bHCG until negative, , defer conception for 3-4 months
Surgical management
Indications
Method
F/U
I: Hemodynamically unstable, persistent excessive bleeding, other CI to medical
M: Laparoscopy GOLD
F/U: Weekly until bHCG -ve
Following salpingotomy, if bHCG fails to fall consider salpingectomy/medical management
Expectant management
Indications
Cautions
F/U
I: Hemodynamically stable
Low or falling bHCG, mass
US findings suggestive of ectopic
Absence of intrauterine gestational sac
Ectopic sac or cardiac activity
Complex adnexal mass
Fluid in culdesac
Mechanism of action of methotrexate
Inhibits conversion of folic acid to folinic acid
Cytotoxic, immunosuppression, anti-inflamatory
Side effects of methtrexate
NV, oral mucositis
Renal/hepatic toxicity
Rash, itch, urticaria
Counselling for use of methotrexate
Same day each week, followed by folic acid following day
Use the same medicine
Avoid conception until 3 months after cessation
Notify if signs of infection, breathing difficulty
Need to monitor blood counts, renal and liver function
