Ectopic pregnancy

Question 1

what is the most common site of an ectopic pregnancy?

Answer 1

the ampulla of the fallopian tube (97%)

Question 2

6 risk factors for an ectopic

Answer 2

previous ectopic
previous PID
previous abdo surgery
smoking
Coil in situ (if they do become pregnant the pregnancy is more likely to be an ectopic)
older age

Question 3

at what stage of pregnancy does an ectopic generally present?

Answer 3

6-8 weeks gestation

Question 4

5 typical presenting features of an ectopic

Answer 4

PV bleeding

missed MP

constant lower abdominal pain
—–>particularly in the iliac fossae

pelvic tenderness

cervical motion tenderness

Question 5

what does shoulder tip pain in an ectopic indicate?

Answer 5

peritonitis

Question 6

what is the investigation of choice for diagnosing an ectopic pregnancy?

Answer 6

transvaginal USS

Question 7

what is meant by “blob sign”/”bagel sign”/tubal ring sign”?

Answer 7

these all refer to the same thing - a non-specific mass seen within the fallopian tubes on USS

Question 8

how can an ectopic pregnancy mass be differentiated to a corpus luteum on USS?

Answer 8

look at the movement of the ovary - a corpus luteum will move with the ovary and a tubal pregnancy will not

Question 9

2 findings within the uterus when performing an USS in an ectopic pregnancy

Answer 9

an empty uterus (!)

fluid within the uterus - AKA “pseudogestational sac”

Question 10

at what level of bHCG should you be able to see a pregnancy on USS?

Answer 10

1500 IU

Question 11

how is pregnancy of unknown location investigated?

Answer 11

with serial HCG - one 48 hours after the first

Question 12

pregnancy of unknown location: which HCG results correspond to…

uterine pregnancy

ectopic pregnancy

miscarriage

Answer 12

rise in HCG of >63%

rise in HCG of <63%

fall in HCG of >50%

Question 13

true or false: all ectopic pregnancies require termination

Answer 13

all ectopic pregnancies will need to be terminated - either naturally or by inducing termination

Question 14

criteria for expectant management of an ectopic

Answer 14

follow-up must be possible
unruptured
no foetal heartbeat
HCG <1500 IU
no significant pain
adnexal mass <1500

Question 15

criteria for medical management of an ectopic

Answer 15

as with expectant, except also:

confirmed absence of intrauterine pregnancy on USS
HCG <5000

Question 16

how is an ectopic pregnancy terminated medically?

Answer 16

with IM methotrexate

Question 17

effect of medical termination of an ectopic on later fertility

Answer 17

patients advised not to get pregnant for 3 months after methotrexate injection because of potential teratogenicity

Question 18

4 common AEs to medical termination of an ectopic pregnancy

Answer 18

stomatitis
PV bleeding
abdo pain
N+V

Question 19

true or false: most patients with an ectopic will require surgical management

Answer 19

true

Question 20

4 criteria which necessitate surgical management of an ectopic pregnancy

Answer 20

HCG 5000+

adnexal mass >35mm

visible foetal heartbeat

significant pain

Question 21

what is the first line surgical management of choice for an ectopic

Answer 21

laparoscopic salpingectomy

Question 22

when may a laparoscopic salpingotomy be used?

Answer 22

when there is a risk to fertility due to damage to the other tube

NB considering that ectopics can recur this probably isn’t that uncommon

Question 23

how commonly do patients who have been treated with a salpingotomy require further management i.e. either methotrexate or a salpingectomy?

Answer 23

20%

Question 24

true or false: all ectopic pregnancies are “sensitising events” for Rh -ve patients

Answer 24

false - but surgical management of an ectopic is, and anti-D should be given prophylactically