Ectopic Pregnancies - Zilberstien

Question 1

What are the major risk factors for ectopic pregnancy?

Answer 1

1/3 from tubal damage (infection, surgery)
1/3 associated with smoking
1/3 unknown cause

Also sterilisation and previous ectopic pregnancy, tubal-factor infertility and previous myomectomy

Risk increases with the number of PID

ART/IVF doubles the risk (from 2-4%)

Contraceptive failure of IUD, sterilization or progestin based

Question 2

What is the typical triad of symptoms for ectopic pregnancy?

Answer 2

Bleeding and abdominal pain after a period of amenorrhea (confusing presentation d/t overlap with
miscarriage)

EP should be considered in all women who present
with a history of fainting and vaginal bleeding

Question 3

What are the differential diagnoses to consider with ectopic pregnancy?

Answer 3

Early intra – uterine pregnancy.
Ruptured Ovarian Cyst
Bleeding Corpus Luteum.
Spontaneous abortion.
Salpingitis.
Appendicitis
Adnexal Torsion
Endometriosis
Diverticulitis

Question 4

What beta-HCG levels are acceptable in normal pregnancy versus predictive of ectopic pregnancy?

Answer 4

Above 67% / 50% in 48h predicts normal pregnancy (with 15% error in either direction)

Should be seen in TVS with levels over 1500IU/L or 2000 if no signs or multiple pregnancies

Best if combined with Transvaginal ultrasonography (TVS), not enough alone

Exponential rise during the first six weeks, after 6 weeks not predictive (lots of variability)

Question 5

What are the indications for serum progesterone concentrations for ectopic pregnancy diagnosis?

Answer 5

Not indicated unless values are extreme

> 80nmol/L: 98% healthy intrauterine pregnancy

< 15nmol/L 99% non-viable pregnancy (85% miscarry)

Most women will have in between and this is not predictive

Question 6

What is the treatment for ectopic pregnancy?

Answer 6

Treatment of choice if hemodynamically stable and compliant: Methotrexate 50mg/m^2

D&C is not done

Laparoscopic surgery (same outcome as open but open done in emergencies)

Salpyngectomy or salpyngostomy
Salpyngectomy : cut fallopian tube and take out (done when tube is damaged)
Salpyngostomy: to preserve the tube, more likely to have remnants and have persistant EP (4-15% chance)
No advantage to one over the other in fertility

MTX used prophylactically to reduce persistent EP

Milking the fimbria is a less desireable option

Preventative:
Most will absortb themselves, make sure to give Anti-D if Rh-

Cornu have blood vessels and expands so high chance of rupture

Question 7

What are the indications and contraindications for methotrexate for ectopic pregnancy?

What is its action?

Answer 7

Folinic acid antagonist, blocks DNA (some RNA) synthesis and cell division, trophoblasts most sensitive

Measure until undetected

15% of women will need another dose (90% successful)

Need to check beta-HCG on days 0, 4 and 7 (day 4 may be higher and that would be baseline), look for at least 15% reduction

7-10% ruptured tubes and need urgent surgery

75% have pain that needs to be waited out (from trophoblast detaching and blood filling implantation site-explain this to patient)

Sometimes alternated with Leucovorin

Absolute contraindications:
Intrauterine pregnancy
Evidence of immunodeficiency
Moderate to severe anaemia, leucopoenia or thrombocytopenia
Sensitivity to MTX
Active pulmonary disease
Active peptic ulcer disease
Clinically important hepatic dysfunction
Clinically important renal dysfunction
Breast feeding

Relative contraindications:
Embryonic cardiac activity (heartbeat) detected by transvaginal ultrasonography
High initial hCG concentration (5,000 mIU/mL)
Ectopic pregnancy 4 cm in size as imaged by transvaginal ultrasonography
Refusal to accept blood transfusion
Inability to participate in follow-up