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Year 5 - Obstetrics and Gynaecology > Ectopic pregnancy > Flashcards

Ectopic pregnancy Flashcards

1
Q

Define ectopic pregnancy.

A

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy

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2
Q

What is a heterotopic pregnancy?

A

The simultaneous development of two pregnancies: one within and one outside the uterine cavity.

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3
Q

What are the clinical features of ectopic pregnancy?

A

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

  • lower abdominal pain
  • vaginal bleeding - less than normal period and may be brown in colour
  • history of recent amenorrhoea - ~6-8 weeks from the start of LMP
  • shoulder tip pain and pain on defecation / urination
  • dizziness, fainting or syncope may be seen
  • symptoms of pregnancy such as breast tenderness may also be reported
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4
Q

Describe the abdominal pain in ectopic pregnancy and why it occurs.

A
  • due to tubal spasm
  • typically the first symptom
  • pain is usually constant and may be unilateral.
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5
Q

If time from LMP is 10 weeks or more, is ectopic still a differential?

A

Unlikely and usually suggests another causes e.g. inevitable abortion

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6
Q

Why might there be shoulder tip pain in ectopic pregnancy?

A

Peritoneal bleeding causes shoulder tip pain

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7
Q

What are the examination findings in ectopic pregnancy?

A

abdominal tenderness

cervical excitation (also known as cervical motion tenderness)

adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

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8
Q

What investigations point towards ectopic pregnancy?

A

Serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

Investigation of choice for diagnosis is a TVUSS

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9
Q

How common are ectopic pregnancies?

A

0.5% of all pregnancies

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10
Q

What are the risk factors for ectopic pregnancy? What pathology are they all linked to?

A

Risk factors - all linked to slowing the ovum’s passage to the uterus

  • previous ectopic
  • damage to tubes (PID, surgery) e.g. Chlamydia, Gonorrhoea
  • endometriosis
  • IUCD
  • progesterone only pill
  • IVF (3% of pregnancies are ectopic) - due to the transfer of two blastocysts
  • Others: smoking, increased maternal age, subfertility, abdominal surery (C/S and appendicectomy
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11
Q

What are the 3 ways of managing an ectopic pregnancy?

A
  • Expectant management
  • Medical management
  • Surgical management
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12
Q

When is expectant management of ectopic pregnancy appropriate?

A
  • Size <35mm
  • Unruptured
  • Asymptomatic
  • No fetal heartbeat
  • hcG <1000 IU/L
  • If there is another intrauterine pregnancy

(those in bold differ from the requirements for medical management)

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13
Q

When is medical management of ectopic pregnancy appropriate?

A
  • Size <35mm
  • Unruptured
  • Minimal pain
  • No fetal heartbeat
  • hCG <1,500 IU/L
  • Not suitable if intrauterine pregnancy

(those in bold differ from requirements for expectant management)

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14
Q

When is surgical management of an ectopic pregnancy required?

A
  • Size >35mm
  • May be ruptured
  • Pain
  • Visible heartbeat
  • hCG>5,000IU/L
  • Compatible with another intrauterine pregnancy*

(those in bold differ from requirements for medical management)

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15
Q

What is the appropriate management of an ectopic with hCG levels 1,400 IU/L, 36mm in size and with another compatible intrauterine pregnancy?

A

Surgical management

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16
Q

What is the appropriate management of an ectopic with hCG levels 1,010 IU/L, 34mm in size and some minimal pain, with a patient unable to attend followup?

A

Surgical management

Medical if the patient were able to attend follow up.

17
Q

What is the management of an ectopic with another intrauterine pregnancy, bHC of 990 IU/L, 25mm and no symptoms?

A

Expectant management

18
Q

What does expectant management of ectopics involve?

A

Closely monitoring the patient over 48 hours

Monitor hCG levels until undetectable - if B-hCG levels rise again or symptoms manifest intervention is performed.

19
Q

What does medical management of ectopics involve?

A

Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.

20
Q

What is the MOA of methotrexate and how is its efficacy monitored?

A

Folic acid antagonist that inhibits DNA synthesis, particularly affecting trophoblastic cells. The dose is 50 mg/m2 (based on body SA).

After treatment serum hCG is usually routinely measured on:

  • days 4, 7 and 11*,
  • then weekly thereafter until undetectable

*levels need to fall by 15% between day 4 and 7, and continue to fall with treatment).

21
Q

What are the contraindications to medical treatment of ectopic pregnancy?

A

The few contraindications to medical treatment include:

  • (1) chronic liver, renal or haematological disorder
  • (2) active infection
  • (3) immunodeficiency
  • (4) breastfeeding
22
Q

What must you warn the patient of when giving medical treatment for ectopic pregnancy? What 3 things must patients avoid on methotrexate?

A

SE: stomatitis, conjunctivitis, gastrointestinal upset and photosensitive skin reaction, and about two-thirds of patients will suffer from non-specific abdominal pain.

  • Avoid sexual intercourse during treatment
  • Avoid conceiving for 3 months after methotrexate treatment because of the risk of teratogenicity.
  • Avoid alcohol and prolonged exposure to sunlight during treatment.
23
Q

What does surgical management of ectopics involve?

A

Laparoscopic salpingectomy (removal of fallopian tube) or salpingostomy.

  • Salpingostomy is only considered if contralateral tube is absent or visibly damaged and is associated with a higher rate of subsequent EP

Laparotomy is reserved for severe cases

24
Q

Does salpingectomy severely affect fertility?

A

Pregnancy rates subsequently remain high if the contralateral tube is normal because the oocyte can be picked up by the ipsilateral or contralateral tube.

25
Q

Where do most ectopic pregnancies occur?

A

Tubal in 97% and most in ampulla

3% in ovary, cervix or peritoneum

26
Q

What is a dangerous location for ectopics to occur in?

A

Isthmus

27
Q

What is the pathophysiology of abortions?

A
  • tubal abortion
  • tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
  • tubal rupture

Bleeding occurs when the trophoblast invades the tubal wall; the bleeding may then dislodge the embryo.

28
Q

Where should you manage a stable vs unstable patient with suspected ectopic pregnancy?

A

Stable - early pregnancy assessment unit

Unstable - emergency department

29
Q

In 1st trimester, volume of fetal blood is small and it is unlikely that sensitisation will occur. Should you therefore give anti-D?

A

Anti-D is only indicated following in the first trimester:

  • ectopic pregnancy,
  • molar pregnancy,
  • therapeutic termination of pregnancy
  • in cases of uterine bleeding where this is repeated, heavy or associated with abdominal pain.

Dose given is 250IU

30
Q

How good is TVUSS at diagnosing ectopic pregnancy?

A

A TVUSS showing an empty uterus with an adnexal mass has a sensitivity of 90% and specificity of 95% in the diagnosis of EP.

31
Q

What are hCG levels like in EP compared to normal pregnancy?

A

The serum hCG level almost doubles every 48 hours in a normally developing intrauterine pregnancy. In patients with EP, the rise of hCG is often suboptimal.

32
Q

What is the working diagnosis when EP is not found but not excluded due to positive pregnancy test?

A

‘Pregnancy of unknown location’ (PUL)

  • In up to 40% of women with an EP the diagnosis is not made on first attendance
  • A PUL is a working diagnosis defined as an empty uterus with no evidence of an adnexal mass on TVUSS (in a patient with a positive pregnancy test)

Year 5 - Obstetrics and Gynaecology (87 decks)

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