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Obstetrics and gynaecology > Ectopic pregnancy > Flashcards

Ectopic pregnancy Flashcards

1
Q

Define ectopic pregnancy

A

Any pregnancy which is implanted at a site outside of the uterine cavity

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2
Q

How many pregnancies in the UK are ectopic?

A

1 in 80-90

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3
Q

Name the common sites ectopics are found

A

Ampulla and isthmus of the fallopian tube
Ovaries
Cervix
Peritoneal cavity

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4
Q

List the risk factors for ectopic pregnancy

A 
Previous ectopic pregnancy 
PID - adhesions
Endometriosis - adhesions 
IUD/IUS
Progesterone oral contraceptive or implant - fallopian tube ciliary dysmotility 
Tubal ligation or occlusion 
Pelvic surgery - especially tubal 
Assisted reproduction - IVF
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5
Q

List the clinical features of ectopic pregnancy

A 
Pain - lower abdominal/pelvic 
Vaginal bleeding 
History of amenorrhea
Shoulder tip pain 
Vaginal discharge
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6
Q

Describe the bleeding from ruptured ectopic

A

Intra-abdominal not vaginal

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7
Q

Why does vaginal bleeding occur in ectopics

A

Result of decidual breakdown in the uterine cavity due to suboptimal B-HCG

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8
Q

Why does shoulder tip pain occur with ectopic pregnancy

A

Irritation of the diaphragm by blood in the peritoneal cavity
Referred pain occurs
Diaphragm and supraclavicular nerves share the C3-5 dermatomes

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9
Q

Describe the vaginal discharge in ectopic pregnancy

A

Brown in colour

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10
Q

Why does brown vaginal discharge occur in ectopic pregnancy

A

Result of the decidua breaking down

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11
Q

What signs on examination may be found?

A

Abdominal tenderness
Vaginal examination - cervical excitation and/or adnexal tenderness

Haemodynamically unstable if ectopic has ruptured - pallor, delayed CRT, tachycardia, hypotension with signs of peritonitis - abdominal rebound tenderness and guarding. Vaginal examination reveals fullness in the pouch of douglas

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12
Q

What is the pouch of douglas?

A

Extension of peritoneal cavity between the rectum and uterus

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13
Q

List some differentials of ectopic pregnancy

A 
Miscarriage
Ovarian cyst accident - torsion, haemorrhage or rupture
Acute Pelvic inflammatory disease
Urinary tract infection
Appendicitis 
Diverticulitis
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14
Q

What investigations are necessary to investigate for an ectopic

A

Pregnancy test (urine bHCG)
If positive bHCG - pelvic USS
Urinalysis - exclude UTI

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15
Q

What is it called when B-HCG is positive but the pregnancy can not be identified on USS

A

Pregnancy of unknown location

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16
Q

What are the main differentials of a pregnancy with unknown location

A

Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy

17
Q

Describe the management of pregnancy of unknown location

A

B-HCG should be taken
If initial B-HCG >1500iU and no IU pregnancy on USS, then considered an ectopic until proven otherise and diagnostic laparoscopy should be offered

If B-HCG <1500 iU and patient is stable, a further blood test can be taken 48hrs later - in a viable pregnancy would be expected to double every 48hrs and in a miscarriage would be expected to half in 48hrs - ectopic wil fall or rise randomly.

18
Q

Describe the medical management of ectopic pregnancy

A

IM methotrexate
Monitoring of bHCG - if no decline then give another methotrexate dose
24/7 access to gynae services and informed of symptoms of rupture

19
Q

What is methotrexate and how does it work in ectopics?

A

Anti-folate cytotoxic agent that disrupts folate dependent cell division of the developing foetus

20
Q

Who is medical management of ectopics given to?

A

Stable
Well controlled pain
bHCG <1500iu/ml
Unruptured ectopic without a visible heartbeat

21
Q

What are the advantages of medical management of ectopics?

A

Avoids the complications of surgical management and patient can be at home after injection

22
Q

What are the disadvantages of medical management of ectopics?

A

Side effects of methotrexate

Treatment failure - surgical intervention

23
Q

What are the side effects of methotrexate

A 
Abdominal pain 
Myelosuppression
Renal dysfunction
Hepatitis 
Teratogenesis
24
Q

How long after methotrexate use should patients be advised to use contraception for?

A

3-6months

25
Q

Describe the surgical treatment of ectopics

A

Laparoscopic salpingectomy

Laparoscopic salpingotomy

26
Q

What is a salpingectomy

A

Removal of the ectopic and the fallopian tube

27
Q

What is a salpingotomy?

A

Cut in the fallopian tube to remove the ectopic and preserve fertility

28
Q

What is required after salpingotomy and why?

A

B-HCG follow up until the level reaches <5iU to ensure no residual trophoblast

29
Q

Who is surgical management of ectopic offered to?

A

Severe pain
Serum B-HCG >5000
Adnexal mass >34
Foetal heartbeat visible on scan

30
Q

What are the advantages of surgical management

A

High success rate

31
Q

What are the disadvantages of surgical treatment

A

Anaesthetic risk
Risk of damage to neighbouring structures (bladder, bowel, ureters, DVT/PE, haemorrhage, infection)
Salpingotomy - some may remain in the tube (treatment failure)

32
Q

Describe conservative management

A

Watchful waiting of the stable patient while allowing ectopic to resolve naturally
Serum B-hcg is monitored over 48hrs to ensure it is falling equal or greater than 50% of the level until it falls to <5mlU/ml

33
Q

Who is conservative management for ectopic offered to?

A 
Rupture unlikely 
Stable patients
Well controlled pain 
Low baseline bHCG
Small unruptured ectopic on USS
34
Q

What are the advantages of conservative management?

A

Avoid risks of medical and surgical management

Can be done at home

35
Q

What are the disadvantages of conservative management?

A

Failure or complications necessitating medical or surgical management (25%)
Rupture of ectopic

36
Q

What are the complications of ectopic pregnancy

A

Untreated - fallopian tube rupture - blood loss causing hypovolaemic shock and organ failure and death

Obstetrics and gynaecology (67 decks)

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