Ectopic Pregnancy Flashcards
What is an ectopic pregnancy?
It is defined as a pregnancy implanted outside the uterus
What is the most common location of an ectopic pregnancy?
Ampulla of the fallopian tube
In what four other locations do ectopic pregnancies commonly occur?
Isthmus of the fallopian tube
Ovaries
Cervix
Peritoneal cavity
In which location is there an increased risk of ectopic pregnancy rupture?
Isthmus
What are the seven risk factors of ectopic pregnancy?
Previous Ectopic Pregnancy
Pelvic Inflammatory Disease
Endometriosis
Fallopian Tube Surgery
Intrauterine Devices
Progesterone Only Pill
In Vitro Fertilisation
When do clinical features of ectopic pregnancies present?
6-8 weeks
What are the six clinical features of ectopic pregnancy?
Unilateral Lower Abdominal Pain
Dark Brown Vaginal Bleeding
Amenorrhoea
Shoulder Tip Pain
Cervical Motion Tenderness
Syncope
What is the first clinical feature patients present with in ectopic pregnancies?
Lower abdominal pain
What is the cause of lower abomdinal pain in ectopic pregnancies?
Tubal spasm
Why does vaginal bleeding occur in ectopic pregnancy?
There is decidual breakdown in the uterine cavity due to suboptimal B-HCG levels
How long is amenorrhoea present for in ectopic pregnancies?
6 - 8 weeks from the start of the last period
Why does shoulder tip pain occur in ectopic pregnancies?
This is due to the pelvic diaphragm being irritated by blood in the peritoneal cavity
The supraclavicular and the pelvic diaphragm share the C3-C5 dermatomes
What is cervical motion tenderness?
This is defined as pain when moving the cervix during a bimanual examination
What three investigations are used to diagnose ectopic pregnancies?
Vaginal Examination
Pregnancy Test
Ultrasound Scan
On examination, what are the two features of ectopic pregnancies?
Abdominal tenderness
Cervical motion tenderness
What should not be examined for in suspected ectopic pregnancies?
Adnexal mass
This is due to the risk of rupture
Which ultrasound scan is preferred to investigate ectopic pregnancies - transabdominal or transvaginal?
Transvaginal
What are the two features of ectopic pregnancies on ultrasound scans?
A Gestational Sac With Yolk Sac/Fetal Pole In Fallopian Tube
Empty Uterus
What are pregnancies of unknown location?
When a pregnancy cannot be identified on an ultrasound scan, however the pregnancy test is positive
What are three differential diagnoses of pregnancies of unknown location?
Early intrauterine pregnancy
Miscarriage
Ectopic pregnancy
How do we investigate patients with pregnancies of unknown location?
Serum HcG levels
How do we manage patients with a pregnancy of unknown location and beta-HCG levels >1500?
This should be considered an ectopic pregnancy
A diagnostic laparoscopy should be offered
How do we manage patients with a pregnancy of unknown location and beta-HCG levels <1500?
A further blood test is taken 48 hours later
At what serum hCG level should a pregnancy be visible on an ultrasound scan?
> 1500
In 48 hours, how would the serum HcG levels change in viable pregnancies?
They would increase more than 63%
In 48 hours, how would the serum HcG levels change in miscarriages?
It would be expected to fall more than 50%
In 48 hours, how would the serum HcG levels change in ectopic pregnancies?
It would be expected to increase less than 63%
What is the most appropriate management step in cases where individuals present with suspected ectopic pregnancy - positive pregnancy test and either abdominal, pelvic or cervical motion tenderness?
Immediate referral to the ealry pregnancy assessment unit
What is the conservative management option of ectopic pregnancies?
It involves watchful waiting of the patient, while allowing the ectopic to terminate naturally
There should be close monitoring of the patient over 48 hours and if serum beta-hCG levels rise or clinical features manifest, intervention should be performed
In which five circumstances is conservative management of ectopic pregnancies recommended?
Ectopic Pregnancy < 35mm
Unruptured Ectopic Pregnancy
Asymptomatic
No Fetal Heartbeat
Serum beta-hCG < 1000IU/L
What is the pharmacological management option of ectopic pregnancies?
IM Methotrexate
How is methotrexate used to treat ectopic pregnancies?
It highly teratogenic drug that halts the progress of the pregnancy and results in spontaneous termination
Once methotrexate has been administered, how do we monitor these ectopic pregnancies?
The serum beta-hCG should be monitored every 48 hours to ensure that it is falling by more than 15% in day four to five
If this decline is not evident, a repeat dose is administered
How long should patients treated with methotrexate wait, before becoming pregnant again? Why?
Three months
This is because the harmful effects of methotrexate persist this long
In which five circumstances is pharmacological management of ectopic pregnancies recommended?
Ectopic Pregnancy < 35mm
Unruptured Ectopic Pregnancy
No Significant Pain
No Fetal Heartbeat
Serum beta-hCG < 1500/L
What are the two surgical management options of ectopic pregnancies?
Laparoscopic Salpingectomy
Laparoscopic Salpingotomy
When is laparoscopic salpingectomy recommended to manage ectopic pregnancies?
In women with no other risk factors for infertility
What is laparoscopic salpingectomy?
It involves removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube
When is laparoscopic salpingotomy recommended?
In women with risk factors for infertility, such as contralateral tube damage to infection, disease, etc
What is laparoscopic salpingotomy?
This procedure involves a cut being made in the affected fallopian tube and the ectopic pregnancy being removed from it
What is a disadvantage of larparoscopic salpingotomy?
There is an increased risk of failure to remove the ectopic pregnancy
These patients may need further treatment with methotrexate
In which five circumstances is surgical management of ectopic pregnancies recommended?
Ectopic Pregnancy > 35mm
Ruptured Ectopic Pregnancy
Significant Pain
Visible Fetal Heartbeat
Serum beta-hCG > 5000IU/L
After surgical management of ectopic pregnancies, what do we administer to all rhesus negative women?
Anti-D prophylaxis
