Ectopic pregnancy

Question 1

Definition

Answer 1

Abnormal implantation of the embryo elsewhere other than the endometrial cavity

Question 2

Sites

Answer 2

Fallopian tube (95%)
Cervix
Abdominal cavity
Ovaries

Question 3

Presentation:

Answer 3

1. Asymptomatic
2. Female of reproductive age with hx of amenorrhea in first trimester
   - LAP
   - PV bleeding

Pregnancy sx:
Breast tenderness
Nausea
Vomiting

Question 4

If ruptured:

Answer 4

Shock: tachycardia
And hypotension
Pallor

Question 5

Risk factors

Answer 5

Previous ectopic
Age

Chronic salpingitis
Infections

IUD

Tubal ligation/surgery
Abdominal surgery( appendectomy, laparotomy)

Smocking

DES in uterine

Question 6

Viable presence: causes of bleeding

Answer 6

Implantation bleeding

Subchorionic haemorrhage

Question 7

Non-viable causes of PV bleeding

Answer 7

Ectopic
Molar
Miscarriage

Question 8

Exam

Answer 8

Vitals -tachycardia and hypotension

Gen-pallor

Abdo- tender ,
Peritonitis

PV - bleeding

Question 9

Shoulder pain

Answer 9

Peritoneal irritation and inflammation

Question 10

Tests

Answer 10

Urine- BHCG and dipstick

Blood - FBC ( anaemia and infection)
Urea and electrolytes (diff kidney stones)
LFT- biliary colic

Question 11

Imaging

Answer 11

Ultrasound:

empty uterus

Free fluid in abdo eg pouch of Douglas

Masses in adnexa

Question 12

Diff

Pregnancy vs non-pregnancy related

Answer 12

Causes of PV bleeding (4)

Non-pregnancy :

Appendicitis 
Kidney stones
UTI
Trauma
Diverticulitis
Ovarian cyst 
Fibroids

Question 13

Other lab test-2?

Answer 13

Quantitative BHCG
-viable preg must increase by atleast 50% every 48 hours in first trimester

• monitor levels: to assess viability and also to check that is it’s over the discriminatory zone

Serum progesterone:
Greater than 20 if healthy pregnancy

Question 14

Approach

Answer 14

1. pregnant - qualitative BHCG levels (urine)
2. Examine- haemodynamically stable
3. Ultrasound - to assess pregnancy location
4. Serial HCG - to confirm or exclude

Question 15

HCG

When is it first dectectable?

Rate of increase in beginning?

What happens in normal pregnancy?

When is single test useful?

Answer 15

Human chorionic gonadotropin
-detachable 21 days post LNMP

• normally: increase in curvilinear fashion up to 41 days and the rises more slowly till 10 weeks.
  2nd and 3rd trimester it declines and plateaus

Single level only useful if used in conjunction with ultrasound

Increase by 66% in 48hours

Question 16

Management

Answer 16

Expectant
Medical
Surgical

Question 17

Expectant

Answer 17

• informed consent
• watchful waiting
• monitor BHCG

But must be early in the pregnancy ( discriminatory zone)
And asymptomatic

Question 18

Medical

Answer 18

Methotrexate -
antifolate : actively dividing cells
50-100mg IM or PO stat

Folic acid- 10mg TDS after 24hours for 3/7

Question 19

Requirements for methotrexate

Answer 19

Well

not ruptured

Patient who can follow up (in 7 days and repeat BHCG)

No feral heart

Diameter less than 3.5 cm

BHCG less than 1000 IU

Normal FBC and UE

Question 20

Complications with metho( too low dose

Answer 20

Alopecia

BM suppression

Mucositis

Gastritis

Question 21

Other medical options

Answer 21

Mifepristone

Potassium chloride

Hyperosmolar glucose

Tyrosine kinase inhibitor: Gefitinib

Question 22

Surgery indications

Answer 22

Ruptured

Haemodynamically unstable patient

Failed medical Mx

Desire sterilisation

Question 23

Surgical options

Answer 23

Laparoscopy > laparotomy

Less blood loss

Shorter hospital stay

Lower costs

Less analgesia

Less adhesions

Question 24

Shock

Answer 24

Amenorrhea 
Pv bleeding
LAP
NV
Dizziness
Collapse

Question 25

Spiel gel berg criteria

Answer 25

6