Ectopic pregnancy Flashcards
Ectopic pregnancy
When a foetus implants outside the uterus
Common site for ectopic implantation
Fallopian tube - ampulla
Risk factors for ectopic pregnancy
Asherman’s syndrome Previous ectopic Previous STI/ PID Previous surgery to the Fallopian tubes IUD Older age Smoking
Presentation of ectopic pregnancy
Pelvic pain - constant lower abdo pain or in the iliac fossae
Missed period
Lower pelvic tenderness
Dizziness/ syncope - blood loss
Shoulder tip pain - peritonitis
Examination findings of an ectopic pregnancy
Cervical motion tenderness - pain when moving the cervix during a bimanual exam
Investigations for an ectopic pregnancy
Speculum/ bimanual exam
Transvaginal USS (diagnostic for diagnosis of miscarriage)
Pelvic USS - rule out appendicitis
Bloods - FBC, CRP, beta HCG
Transvaginal USS findings for ectopic pregnancy
Mass outside of uterus - blob/bagel/tubal ring sign
Moves separately with the ovary (distinguish between the corpus luteum)
Empty uterus
Fluid in the uterus - pseudogestational sac
Pregnancy of unknown location
Positive pregnancy test but no evidence of pregnancy on the USS
Investigations for a pregnancy of unknown location
Beta HCG - repeated after 48 hours
Repeat USS after 1 - 2 weeks
When does the beta HCG level indicate a non intrauterine pregnancy
Rise of > 63% after 48 hours
- indicates ectopic to POL
When should pregnancy be visible on USS
Beta HCG > 1500 IU/L
When is a miscarriage indicated
A fall of the Beta HCG of > 50%
Investigation for miscarriage
Repeat Beta HCG
Repeat urine pregnancy test after 2 weeks
Management of ectopic pregnancy
Medical emergency
Terminate pregnancy
How to terminate a pregnancy
Expectant management - awaiting natural termination
Medical management - methotrexate
Surgical management - salpingectomy or salpingotomy
Criteria for expectant management
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
Criteria for methotrexate
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
How is methotrexate given
Intramuscular injection into a buttock
Advice with methotrexate
Not to get pregnant for 3 months following treatment as teratogenic
Side effects of methotrexate
- Vaginal bleeding
- Nausea and vomiting
- Abdominal pain
- Stomatitis (inflammation of the mouth)
Criteria for surgical management
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
First line surgery for an ectopic pregnancy
Laparoscopic salpingectomy - general anaesthetic and removal of the affected fallopian tube with the ectopic pregnancy
When is laparoscopic salpingotomy used
For women at increased risk of infertility due to damage of the other tube
Laparoscopic salpingotomy
A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed
Increased failure rate when compared to a salpingectomy
Anti-rhesus D prophylaxis
Given to rhesus negative women having surgical management of ectopic pregnancy
