Ectopic Pregnancy Flashcards by amo x

What is an ectopic pregnancy?

It is defined as a pregnancy implanted outside the uterus

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What is the most common location of an ectopic pregnancy?

Ampulla of the fallopian tube

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In what four other locations do ectopic pregnancies commonly occur?

Isthmus of the fallopian tube

Ovaries

Cervix

Peritoneal cavity

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In which location is there an increased risk of ectopic pregnancy rupture?

Isthmus

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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

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When do clinical features of ectopic pregnancies present?

6-8 weeks

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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

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What is the first clinical feature patients present with in ectopic pregnancies?

Lower abdominal pain

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What is the cause of lower abomdinal pain in ectopic pregnancies?

Tubal spasm

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Why does vaginal bleeding occur in ectopic pregnancy?

There is decidual breakdown in the uterine cavity due to suboptimal B-HCG levels

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How long is amenorrhoea present for in ectopic pregnancies?

6 - 8 weeks from the start of the last period

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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

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What is cervical motion tenderness?

This is defined as pain when moving the cervix during a bimanual examination

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What three investigations are used to diagnose ectopic pregnancies?

Vaginal Examination

Pregnancy Test

Ultrasound Scan

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On examination, what are the two features of ectopic pregnancies?

Abdominal tenderness

Cervical motion tenderness

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What should not be examined for in suspected ectopic pregnancies?

Adnexal mass

This is due to the risk of rupture

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Which ultrasound scan is preferred to investigate ectopic pregnancies - transabdominal or transvaginal?

Transvaginal

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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