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
Preferred surgical treatment ectopic pregnancy in women with normal contralateral fallopian tubes?
Salpingectomy or partial Salpingectomy
Preferred surgical treatment ectopic pregnancy in women with absent / pathological contralateral fallopian tubes?
Salpingostomy
Offer methotrexate post op to avoid persistent trophoblast activity. Must follow up with bhcg weekly until undetectable
Investigations for suspected ectopic? (6)
- Hb
- type /screen
- serum bhcg
- rhesus status
- Pretreatment evaluation for methotrexate: U+e, LFT
- ultrasound
