Ectopic pregnancy Flashcards
Define ectopic pregnancy.
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
What is a heterotopic pregnancy?
The simultaneous development of two pregnancies: one within and one outside the uterine cavity.
What are the clinical features of ectopic pregnancy?
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
Describe the abdominal pain in ectopic pregnancy and why it occurs.
- due to tubal spasm
- typically the first symptom
- pain is usually constant and may be unilateral.
If time from LMP is 10 weeks or more, is ectopic still a differential?
Unlikely and usually suggests another causes e.g. inevitable abortion
Why might there be shoulder tip pain in ectopic pregnancy?
Peritoneal bleeding causes shoulder tip pain
What are the examination findings in ectopic pregnancy?
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
What investigations point towards ectopic pregnancy?
Serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
Investigation of choice for diagnosis is a TVUSS
How common are ectopic pregnancies?
0.5% of all pregnancies
What are the risk factors for ectopic pregnancy? What pathology are they all linked to?
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
What are the 3 ways of managing an ectopic pregnancy?
- Expectant management
- Medical management
- Surgical management
When is expectant management of ectopic pregnancy appropriate?
- 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)
When is medical management of ectopic pregnancy appropriate?
- 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)
When is surgical management of an ectopic pregnancy required?
- 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)
What is the appropriate management of an ectopic with hCG levels 1,400 IU/L, 36mm in size and with another compatible intrauterine pregnancy?
Surgical management
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?
Surgical management
Medical if the patient were able to attend follow up.
What is the management of an ectopic with another intrauterine pregnancy, bHC of 990 IU/L, 25mm and no symptoms?
Expectant management
What does expectant management of ectopics involve?
Closely monitoring the patient over 48 hours
Monitor hCG levels until undetectable - if B-hCG levels rise again or symptoms manifest intervention is performed.
What does medical management of ectopics involve?
Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.
What is the MOA of methotrexate and how is its efficacy monitored?
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).
What are the contraindications to medical treatment of ectopic pregnancy?
The few contraindications to medical treatment include:
- (1) chronic liver, renal or haematological disorder
- (2) active infection
- (3) immunodeficiency
- (4) breastfeeding
What must you warn the patient of when giving medical treatment for ectopic pregnancy? What 3 things must patients avoid on methotrexate?
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.
What does surgical management of ectopics involve?
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
Does salpingectomy severely affect fertility?
Pregnancy rates subsequently remain high if the contralateral tube is normal because the oocyte can be picked up by the ipsilateral or contralateral tube.
