Ectopic Flashcards
What are the differential diagnosis of 1st trimester bleeding
1- ectopic pregnancy 2- abortion 3- infection 4- trauma 5- molar pregnancy
What is ectopic pregnancy?
The embryo implants outside endometrium cavity
Where is the normal zygote usually gets implanted?
In the uterus (endometrium)
What are the extrauterine sites for implantation of uterus?
- tubal
- ovarian
- abdominal
What are the subtypes of tubal ectopic pregnancy
1- interstitial
2- isthmus
3- infundibular
4- ampulla
Where is the commonest site for implantation in ectopic pregnancy? And why?
Ampulla
because
- it’s the widest diameter
- fertilization site
What is the least extra-uterine site?
Abdominal
What are the intra-uterine sites for implantation in ectopic pregnancy?
- cervical
- cornual
can the ectopic pregnancy in the ampulla continue to full term?
No the tube is very small
Which implantation shows signs and symptoms earlier
- ampulla
- interstitium
- infundubular
- isthimus
Isthimus
Which implantation shows signs and symptoms later
- ampulla
- interstitium
- infundubular
- isthimus
Ampulla
Cornual and cervical ectopic pregnancies are very difficult to manage, that is due to:
The great vascularity.
What is the presentation of ectopic pregnancy
Pain due to serosa enlargement causing peritoneal irritation
What is the fate of untreated ectopic pregnancy (late presentation to the hospital)
Rupture and internal bleeding, could lead to shock
What are the risk factors for ectopic pregnancy
1- prev ectopic pregnancy 2- previous genital infection 3- abnormalities of fallopian tube or uterus 4- infertility - IVF 5- tubual sterilization - IUCD 6- mutliple sexual parteners 7- advanced age 8- previous pelvic surgery 9- ciliary dyskinesia
What is the characterstic of blood in ectopic pregnancy?
Dark and scanty
What is the presentation of ectopic pregnancy
1- pain
2- missed period
3- bleeding
4- pregnancy sx (breast tenderness, urination, nausea)
What is the characteristic of pain in ectopic pregnancy
Constant cramp like, may radiate to shoulder or associated with fainting.
What causes the fainting in ectopic pregnancy?
Blood tracks to the diaphragm and irritate the phernic nerve
The patient presented with positive pregnancy test, missed period and few spotting of dark blood, you will suspect
Ectopic pregnancy
If ectopic pregnancy was not detected, what could be the complications?
Shock or peritonitis
What are the symptoms of shock
Tachycardia, hypotension, loss of consiousness
What are the symptoms of peritoneal irritation?
Gardening - fever - frequency micturation
What are the findings you will see in severe internal bleeding when you preform pelvic examinaition
Adnexal fullness and extreme tenderness on cervical motion
How to diagnose ectopic pregnancy
1- history of LMP, lower abdominal pain, delayed menses, spotting
2- positive pregnancy test
3- US if B-HCG >1000
4- laparoscopy
When to preform laproscopy for ectopic pregnancy
In hemodynamically stable patient, if we can’t detect pregnancy by US
What are the ddx of ectopic pregnancy
1- salpingitis
2- abortion
3- appendicitis
4- ovarian cyst (torsion of the pedicle)
5- rupture of corpus luteum\follicular cyst
6- perforation of peptic ulcer
what is the general approach for management of ectopic pregnancy?
- surgical
- medical (methotrexate)
- resucitation if unstable
When to start investigating for a female with suspected ectopic pregnancy
Lower abdominal pain (+-bleeding) with positive pregnancy test
OR
Asymptomatic with RF for ectopic pregnancy and positive pregnancy test
What is the next step after suspecting ectopic pregnancy?
Doing US (if sure of date), doing B-HCG (if unsure)
What is the cutoff point for HCG to start suspecting ectopic pregnancy
> 1000
What determines if you can give methotrexate or not?
If empty uterus + B-hcg >1000 + meet criteria for methotrexate treatment
What if the patient has ectopic pregnancy but does not meet methotrexate criteria
- salpingotomy: to remove product of convception
- salpingectomy: if the tube is damaged
(By laproscopy or laprotomy)
How to resuscitate a patient with internal hemorrhage due to ectopic pregnancy?
Double IV lines (RBC transfusion - volume expanders)»_space; then proceed with laprotomy
What are the indication to go for surgery in ectopic pregnancy
1- worsening abdominal pain
2- hemodynamically unstable
3- failed methotrexate (Hcg did not decline - increased or platued after 1st week)
