Ectopic pregnancy Flashcards
Define ectopic pregnancy
Any pregnancy which is implanted at a site outside of the uterine cavity
How many pregnancies in the UK are ectopic?
1 in 80-90
Name the common sites ectopics are found
Ampulla and isthmus of the fallopian tube
Ovaries
Cervix
Peritoneal cavity
List the risk factors for ectopic pregnancy
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
List the clinical features of ectopic pregnancy
Pain - lower abdominal/pelvic Vaginal bleeding History of amenorrhea Shoulder tip pain Vaginal discharge
Describe the bleeding from ruptured ectopic
Intra-abdominal not vaginal
Why does vaginal bleeding occur in ectopics
Result of decidual breakdown in the uterine cavity due to suboptimal B-HCG
Why does shoulder tip pain occur with ectopic pregnancy
Irritation of the diaphragm by blood in the peritoneal cavity
Referred pain occurs
Diaphragm and supraclavicular nerves share the C3-5 dermatomes
Describe the vaginal discharge in ectopic pregnancy
Brown in colour
Why does brown vaginal discharge occur in ectopic pregnancy
Result of the decidua breaking down
What signs on examination may be found?
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
What is the pouch of douglas?
Extension of peritoneal cavity between the rectum and uterus
List some differentials of ectopic pregnancy
Miscarriage Ovarian cyst accident - torsion, haemorrhage or rupture Acute Pelvic inflammatory disease Urinary tract infection Appendicitis Diverticulitis
What investigations are necessary to investigate for an ectopic
Pregnancy test (urine bHCG)
If positive bHCG - pelvic USS
Urinalysis - exclude UTI
What is it called when B-HCG is positive but the pregnancy can not be identified on USS
Pregnancy of unknown location
What are the main differentials of a pregnancy with unknown location
Very early intrauterine pregnancy
Miscarriage
Ectopic pregnancy
Describe the management of pregnancy of unknown location
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.
Describe the medical management of ectopic pregnancy
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
What is methotrexate and how does it work in ectopics?
Anti-folate cytotoxic agent that disrupts folate dependent cell division of the developing foetus
Who is medical management of ectopics given to?
Stable
Well controlled pain
bHCG <1500iu/ml
Unruptured ectopic without a visible heartbeat
What are the advantages of medical management of ectopics?
Avoids the complications of surgical management and patient can be at home after injection
What are the disadvantages of medical management of ectopics?
Side effects of methotrexate
Treatment failure - surgical intervention
What are the side effects of methotrexate
Abdominal pain Myelosuppression Renal dysfunction Hepatitis Teratogenesis
How long after methotrexate use should patients be advised to use contraception for?
3-6months
Describe the surgical treatment of ectopics
Laparoscopic salpingectomy
Laparoscopic salpingotomy
What is a salpingectomy
Removal of the ectopic and the fallopian tube
What is a salpingotomy?
Cut in the fallopian tube to remove the ectopic and preserve fertility
What is required after salpingotomy and why?
B-HCG follow up until the level reaches <5iU to ensure no residual trophoblast
Who is surgical management of ectopic offered to?
Severe pain
Serum B-HCG >5000
Adnexal mass >34
Foetal heartbeat visible on scan
What are the advantages of surgical management
High success rate
What are the disadvantages of surgical treatment
Anaesthetic risk
Risk of damage to neighbouring structures (bladder, bowel, ureters, DVT/PE, haemorrhage, infection)
Salpingotomy - some may remain in the tube (treatment failure)
Describe conservative management
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
Who is conservative management for ectopic offered to?
Rupture unlikely Stable patients Well controlled pain Low baseline bHCG Small unruptured ectopic on USS
What are the advantages of conservative management?
Avoid risks of medical and surgical management
Can be done at home
What are the disadvantages of conservative management?
Failure or complications necessitating medical or surgical management (25%)
Rupture of ectopic
What are the complications of ectopic pregnancy
Untreated - fallopian tube rupture - blood loss causing hypovolaemic shock and organ failure and death
