ectopic pregnancy

Question 1

what are the risk factors for an ectopic pregnancy?

Answer 1

Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking

Question 2

when do ectopics usually present?

Answer 2

6-8 weeks gestation

Question 3

what are the classic features for ectopic pregnancy?

Answer 3

Missed period
Constant lower abdominal pain in the right or left iliac fossa
Vaginal bleeding
Lower abdominal or pelvic tenderness
Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

It is also worth asking about:

• Dizziness or syncope (blood loss)
• Shoulder tip pain (peritonitis)

Question 4

what are the 3 methods of managing an ectopic pregnancy?

Answer 4

1. Expectant management (awaiting natural termination)
2. Medical management (methotrexate)
3. Surgical management (salpingectomy or salpingotomy)

Question 5

what are some differentials for ectopic pregnancy?

Answer 5

• Miscarriage
• Ruptured ovarian corpus luteal cyst.
• Pregnancy-related degeneration of a fibroid.

Question 6

what is the criteria for expectant management of ectopic pregnancy?

Answer 6

Follow up needs to be possible to ensure successful termination

• The ectopic needs to be unruptured
• Adnexal mass < 35mm
• No visible heartbeat
• No significant pain
• HCG level < 1500 IU / l

Question 7

what is the criteria for managing an ectopic pregnancy with methotrexate?

Answer 7

• HCG level must be < 5000 IU / l
• adnexal mass <35mm
• no visible heart beat
• ectopic unruptured
• Confirmed absence of intrauterine pregnancy on ultrasound

Question 8

how long should women who have taken methotrexate wait before they get pregnant?

Answer 8

3 months- because of harmful effects on baby

• methotrexate is given as an IM injection

Question 9

what additional medication may you need to give surgical ectopic pregnancy patients?

Answer 9

-Anti-D if rh-

Question 10

what are common side effects of methotrexate?

Answer 10

Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)

Question 11

what is the criteria for managing an ectopic with surgery?

Answer 11

Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l

Question 12

what are the 2 surgical options for ectopic pregnancies?

Answer 12

Laparoscopic salpingectomy- removal of the affected Fallopian tube

Laparoscopic salpingotomy- removal of the ectopic pregnancy- may need further treatment with methotrexate or salpingostomy

Question 13

which surgical approach to ectopic pregnancy is first line?

Answer 13

salpingectomy- salpingOTOMY- only performed if woman’s fertility is threatened due to problem/ previous surgery on her other tube

Question 14

where is the most dangerous location for an ectopic pregnancy?

Answer 14

the isthmus of the Fallopian tube- most likely to rupture here

Question 15

what is then most appropriate first step to managing suspected ectopic pregnancy?

Answer 15

refer to EPU- especially if >6 weeks pregnant

if < 6 weeks and woman is bleeding but no pain and other risk factors for ectopic then she can be managed expectantly:

• return if bleeding continues or pain develops
• repeat pregnancy test in 7-10 days-> negative would suggest miscarriage

Question 16

which is better- salpingectomy or atomy?

Answer 16

ectomy id nothing is wrong with the other tube

Question 17

what are risk factors for ectopic pregnancy?

Answer 17

• damage to tubes (pelvic inflammatory disease, surgery)
• previous ectopic
• endometriosis
• IUCD
• progesterone only pill
  IVF (3% of pregnancies are ectopic)

Question 18

how is a pregnancy of unknown location managed?

Answer 18

• pregnancy test is positive but no pregnancy is seen on ultrasound
• take another HCG test in 48 hours-> if goes up by >63% then do an USS in 1-2 weeks
• if <63% then may be ectopic- monitor and review
• if <50% - miscarriage