Ectopic Pregnancy Flashcards
Where does tubal ectopic pregnancy most commonly occur
Ampulla
Where does ligamentous ectopic pregnancy most commonly occur
Broad ligament
Classic triad symptoms of ectopic pregnancy
1 amenorrhea
2 vag bleeding
3 abdo pain
Mostly asymptomatic.
dx Of ectopic pregnancy
- B-hCG - compare 2 measurements 48h apart. ≤35% increase.
- u/s - empty uterus + cystic mass to exclude intrauterine pregnancy
Uterine pregnancy should be visible on TV us when bhcg 1000 - 2000 and abdominal us at 6500. - confirmed with distinct adnexal mass on either side of or in pouch of Douglas on ultrasound.
Must be < 20 weeks. > 20 weeks = advanced extra-uterine pregnancy
Criteria for expectant rx for ectopic pregnancy (4)
- Unruptured
- b-hcg < 1000
- b- HCG decrease over 48h (follow up every 48 hours)
- clinically stable / asymptomatic / no haemodynamic compromise
- ectopic < 4cm at time of diagnosis
Only if very early asymptomaticwith possible ectopic or inconclusive ultrasound
Which medical rx use for ectopic pregnancy
Methotrexate
Name 7 criteria that must be met before initiating medical rx for ectopic pregnancy
• unruptured • 100% certainty of location of pregnancy; no co existing intrauterine heterotopic pregnant • B-HCG < 5000 mIU/ml ( > 2000 increase odds failure X4,5) • No fetal cardiac activity on TV u/s • Hemodynamically stable • Sac < 4 cm • No contraindications to methotrexate • ability to follow up after rX with serial b-hcg measurements until undetectable levels
When do surgical rx for ectopic pregnancy (5)
Majority of women when as stable as possible,but surgery part of resus.
•unruptured • B-HCG >3000 • Fetal cardiac activity on u/s Sac > 4 cm (AKA not fit for medical treatment) Or •ruptured
Risk factors ectopic pregnancy? (7)
Embryonal factors
- chromosomal, structural abnormalities
Maternal factors
- History previous PID!
- endometriosis, congenital abnormalities of fallopian tube
- AMA
- cigarette smoking
- infertility, infertility treatment IVF
- previous ectopic
- previous tubal surgery eg salpingostomy (remove contents) or tubal re-anastomosis
IUD and progesterone only contraception: increased risk ectopic in event of contraceptive failure
Symptoms and signs ruptured ectopic? (3)
- Worsened abdominal pain with blood in peritoneal cavity, peritonism/rebound tender
- ultrasound: free fluid in abdomen
- hypovolaemic shock
Name the 3 treatment options for ectopic
Expectant
Medical
- methotrexate
Surgical (majority) (with or without medical adjuvant)
- laparoscopic preferred:
- access salpingectomy,
- partial salpingectomy
- salpingostomy
- laparotomy
Methotrexate moa
Folic acid antagonist that interferes with DNA synthesis and cell proliferation
(Used for medical management ectopic)
Methotrexate medical contraindications (8)
- Severe renal impairment
- severe hepatic impairment
- alcohol abuse
- blood dyscrasias eg blood cancer, anemia, haemophilia, clotting disorders
- bone marrow hypoplasia
- leukopenia
- immunodeficiency: tb, HIV esp uncontrolled
- oral ulcers, active gi ulcer disease
Name 6 side effects methotrexate
Dose dependent toxicity
- Stomatitis
- conjunctivitis
- gastritis
- impaired liver function
- bone narrow depression
- photosensitivity
When may medical management for ectopic be preferred to surgical? (3)
- Cervical ectopic
- cesearean scar ectopic
- already treated surgically with salpingostomy to lower risk persistent trophoblast activity
