Ectopic and PUL

Question 1

What are the most common sites of ectopic pregnancy and what is the most dangerous?

Answer 1

• Most common location = Ampulla
  
  • Ovary, uterus, broad ligament, abdomen
• Highest risk of rupture = Isthmus

Question 2

What are the risk factors for ectopics/PUL?

Answer 2

• Damaged tubes
  
  • Infection/PID
  • Surgery
  • Endometriosis
  • Previous tubal surgery
• IVF
• Previous ectopic (10% recurrence)
• Pregnancy with IUD/IUS
• Depo-Provera injection

Question 3

What are the signs and symptoms of ectopic/PUL?

Answer 3

• Abdominal pain
• Amenorrhoea 4-10 weeks, ± PV bleeding (scanty dark blood)
• Diarrhoea
• Shoulder tip or Back pain
  
  • Blood in recesses irritates surrounding viscera
• Dizziness
• If ruptured → present with circulatory collapse
• On examination:
  
  • Abdomen – rebound tenderness ± guarding
  • Vaginal – cervical excitation, adnexal tenderness ± mass

Question 4

What are the signs and symptoms of a ruptured ectopic pregnancy?

Answer 4

Circulatory collapse

Question 5

What are the appropriate investigations for suspected ectopic/PUL?

Answer 5

Pregnancy test → Speculum → TVUSS

• PUL = serial b-hCG (at 0 and 48 hours)
  
  • Increase in serum bhCG >63% → developing pregnancy - rescan in 7-14 days
  • Increase in serum bhCG <63% to a decrease in serum bhCG <50% → review in EPAU <24 hours
  • Decrease in serum bhCG >50% → miscarriage → expectant management
• Bimanual and speculum
• Bloods – FBC, clotting, cross match
• USS signs
  
  • Tubal = ‘bagel’ sign, ‘blob’ sign
  • Cervical = ‘barrel’ cervix, -ve sliding sign, below internal Os

Question 6

What changes in bhCG indicate prognosis of a pregnancy?

Answer 6

• Increase in serum bhCG >63% → developing pregnancy - rescan in 7-14 days
• Increase in serum bhCG <63% to a decrease in serum bhCG <50% → review in EPAU <24 hours
• Decrease in serum bhCG >50% → miscarriage → expectant management

Question 7

What is the management of ectopic/PUL?

Answer 7

• Medical = x1 IM methotrexate injection - if
  
  • Stable
  • Asymptomatic
  • No blood in pouch of Douglas
  • Normal LFTs/U&Es
  • bHCG <3,000 IU/L
  • Ectopic <35mm + No FH detected
• Surgery – laparoscopic salpingectomy
  
  • Significant pain
  • Adnexal mass >35mm
  • Ectopic with foetal HR
  • bhCG >5,000IU/L
    
    • Anti-D prophylaxis required

Question 8

What should be expected (including side effects) of someone taking medical management of an ectopic?

Answer 8

• Expectations
  
  • Go home → come back for repeat blood tests
  • No intercourse for 3 months
  • Don’t drink alcohol
  • Avoid excessive sun exposure
  • Be prepared for emotions
• SEs
  
  • Pain
  • Nausea and diarrhoea (first few days)

Question 9

What should not be used in a patient who has had a laparoscopic salphingectomy?

Answer 9

Copper IUD

Question 10

What are the complications of an ectopic/PUL?

Answer 10

• Rupture
• Haemorrhage
• Death - 5 per year in the UK
• Tubal infertility
• Psychological sequelae
• Recurrence - 15% risk