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OB-Gyn > Ectopic Pregnancy > Flashcards

Ectopic Pregnancy Flashcards

1
Q

Most common location of ectopic pregnancy

A

Fallopian tubes

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2
Q

Most common location of ectopic pregnancy in Fallopian tubes

A

Ampullary (81%)

Isthmus (12%)
Fimbriae (5%)
Cornual/Interstitial (2%)

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3
Q

Where in the fallopian tubes do tubal ruptures within few weeks usually occurs?

A

Isthmus

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4
Q

Risk Factors of Ectopic Pregnancy

A
  • Hx of Ectopic Pregnancy
  • Postsalpingectomy
  • Post-reversal of sterilization
  • Clomiphene
  • Copper IUD
  • Pelvic Organ Prolapse
  • Progesterone rel. IUD
  • Causes of peritubal adhesions (Infection, Smoking, AA/Endometriosis)
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5
Q

Classic Triad in Ectopic Pregnancy

A

Amenorrhea
Pain
Vaginal Bleeding or Spotting

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6
Q

Clinical Manifestations of Ectopic Pregnancy

A 
Amenorrhea
Pain
Vaginal Bleeding or Spotting
(+/-) Syncope/Vertigo
Diaphragmatic irritation
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7
Q

Symptoms of ruptured ectopic

A

Cervical Motion tenderness
Hypotension
Bradycardia
Bulging posterior fornix (Blood in cul de sac)

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8
Q

Laboratory Diagnosis of Ectopic Pregnancy

A

(+) Beta HCG at >1500 mIU/mL

(+) Serum Progesterone at 10-25 ng/mL

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9
Q

Sonographic Diagnosis of Ectopic Pregnancy

A

Transvaginal UTZ

Transabdominal UTZ

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10
Q

At what level does pregnancy test turns positive

A

10-20 mIU/L

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11
Q

Serum progesterone <5 ng/mL indicates

A

FDU/ectopic

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12
Q

Serum progesterone >25 ng/mL indicates

A

Excludes ectopic Pregnancy

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13
Q

What can you see on a TV-UTZ of an ectopic preganancy

A

Trilaminar pattern

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14
Q

When can you only use transabdominal UTZ on a uterine preganancy

A

28 days after timed ovulation (5-6 menstrual wks)

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15
Q

When can you detect the gestational sac in a TV-UTZ?

A

4.5-5 wks

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16
Q

When can you detect the yolk sac in a TV-UTZ?

A

5-6 wks

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17
Q

When can you detect the fetal pole with heartbeat in a TV-UTZ?

A

5.5-6 wks

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18
Q

What are the multimodality diagnosis?

A 
TV-UTZ
Serum B-Hcg
Serum progesterone
Uterine curettage
Laparoscopy/Laparotomy
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19
Q

How do you do culdocentesis to diagnose ectopic pregnancy?

A

Aspirate on the posterior fornix. If it does not clot, it’s positive for ectopic pregnancy.

20
Q

Surgical Management for Ectopic Pregnancy and differentiate each

A

Salpingostomy - Linear incision at the antimesenteric border; LEFT UNSUTURED to heal by secondary intervention
Salpingotomy - Same as above but SUTURED
Salpingectomy - tubal resection, cornual (1/3 of the interstitial portion)

21
Q

Contraindications for Methotrexate

A 
Abdominal hemorrhage
Intrauterine Pregnancy
Breastfeeding
Immunodeficiency
Chronic Renal Disease
Chronic hepatic disease
Chronic Pulmonary Disease
Blood dyscrasia
Peptic Ulcer Disease
22
Q

What is the single best prognostic indicator of successful treatment using one dose of Methotrexate

A

Initial Beta HCG

23
Q

Failure rate if Beta HCG is <1000 mIU/mL

24
Q

Failure rate if Beta HCG is <2000 mIU/mL

25
Q

Failure rate if Beta HCG is <5000 mIU/mL

26
Q

Failure rate if Beta HCG is <10000 mIU/mL

27
Q

What should be monitored becuase its associated with an increased failure rate

A

Fetal cardiac activity

28
Q

Size of ectopic pregnancy with a success rate of 93% with methotrexate

29
Q

Size of ectopic pregnancy with a success rate of 87-90% with methotrexate

30
Q

Regimens of Methotrexate

A 
Single dose: 50mg/m2, IM
Two doses: 50mg/m2, IM on day 1 and day 4
Multiple doses (7 days)
 - 10mg/m2, IM on odd days
 - Leucovorin 1mg/kg on days even days
 - Stop if B-HCG is >15%
 -Start surveillance q7 days
31
Q

SE of methotrexate

A 
Liver toxicity
Stomatitis
Gastroenteritis
Myelosuppression
Mild separation pain
32
Q

Criteria for medical management

A
  1. Stable patient
  2. B-HCG <1500
  3. <3.5cm
  4. <6 wks
  5. No FHR
33
Q

Indications for an expectant management

A
  • Tubal pregnancy
  • Low serum Beta-HCG
  • Diameter of ectopic mass is NOT >3.5
  • No intraabdominal bleeding or rupture

*These will lead to spontaneous resolution

34
Q

Prognosis for ectopic pregnancies

A

It drops to 60% but
if G1, 35%
if G4 and above, 80%

35
Q

S/sx + Lab of abdominal pregnancy

A

SSx: Pain, N/V, Bleeding, Decreased of absent fetal movement

Elevated maternal AFP

36
Q

Risk factors of abdominal pregnancy

A

Follows early tubal rupture or abortion

37
Q

Medications given before to ectopic pregnancy with PID

A

Px: Doxycycline 100mg BID for 4 days (for chlamydia), Ceftriaxone 250mg IM (for gonorrhea)

Partner: Doxycycline 100mg BID for 7 days (for chlamydia), Ceftriaxone 250mg IM (for gonorrhea)

38
Q

Updated medication for ectopic pregnancy with PID

A

Ertapenem 1g in 3.2mL 1% lidocaine IM
OR
Ertapenem 1g in 10mL sterile water, transfer to 50mL NSS x 30 mins, IV

39
Q

When can you say its already a persistent ectopic pregnancy?

A

When there is an incomplete removal of the trophoblast

40
Q

What are the risk factor of a persistent ectopic pregnancy?

A

Small pregnancy (<2cm)
Early therapy (<42 menstrual days)
Serum B-HCG > 3000 mIU/mL
Implantation medial to slapingostomy site

41
Q

What are the diagnostic exams of a persistent ectopic pregnancy?

A

B-HCG > 1000 mIU/mL on day 7 post sx
B-HCG > 15% of original on day 7 post sx
B-HCG > 15% of original on day 9 post sx
Progesterone > 1.5 ng/mL on day 9 post sx

42
Q

Highest risk factor in the development of ectopic pregnancy

a. Previous abortus
b. Previous tubal surgeries
c. Pelvic inflammatory disease
d. Use of artificial reproductive technology (ART)

43
Q

23 y/o G2P1 (0010) came in due to 6 weeks missed menses with hypogastric pain (pain scale 9/10) associated with vaginal spotting. Patient has a history of incomplete abortion (which was completed via curettage). How do you initially approach this patient?

a. Request for transvaginal ultrasound
b. Request for serum BHCG
c. Request for pregnancy test
d. Perform internal examination

44
Q

One hour after, patient developed hypotension (80/40), tachycardia (130 BPM), and decreased sensorium. What is your NEXT best step? *

a. In cases of ruptured ectopic pregnancy, hypovolemia is expected so reassure the patient and wait for pending lab results
b. Hydrate the patient using crystalloids and blood products
c. Search for possible cause of hypovolemia via transvaginal ultrasound
d. Immediately send the patient to OR for pelvic laparotomy

45
Q

Upon opening up the abdomen, you visualized a ruptured ectopic pregnancy located in the ampulla measuring 6 x 5 x 4 cms. You also noted a hemoperitoneum which measures 1500cc. What is your NEXT step as the main surgeon?

a. Perform salpingectomy
b. Perform salpingostomy
c. Replace the hemoperitoneum with blood products and crystalloid
d. Search for possible source of bleeding and ligate the bleeders

46
Q

What does it indicate if TV-UTZ shows a ring of fire pattern?

A

Tubal preganancy

OB-Gyn (7 decks)

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