Ectopic pregnancy

Question 1

Ectopic pregnancy

Answer 1

When a foetus implants outside the uterus

Question 2

Common site for ectopic implantation

Answer 2

Fallopian tube - ampulla

Question 3

Risk factors for ectopic pregnancy

Answer 3

Asherman’s syndrome 
Previous ectopic 
Previous STI/ PID 
Previous surgery to the Fallopian tubes 
IUD 
Older age 
Smoking

Question 4

Presentation of ectopic pregnancy

Answer 4

Pelvic pain - constant lower abdo pain or in the iliac fossae
Missed period
Lower pelvic tenderness

Dizziness/ syncope - blood loss
Shoulder tip pain - peritonitis

Question 5

Examination findings of an ectopic pregnancy

Answer 5

Cervical motion tenderness - pain when moving the cervix during a bimanual exam

Question 6

Investigations for an ectopic pregnancy

Answer 6

Speculum/ bimanual exam

Transvaginal USS (diagnostic for diagnosis of miscarriage)

Pelvic USS - rule out appendicitis

Bloods - FBC, CRP, beta HCG

Question 7

Transvaginal USS findings for ectopic pregnancy

Answer 7

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

Question 8

Pregnancy of unknown location

Answer 8

Positive pregnancy test but no evidence of pregnancy on the USS

Question 9

Investigations for a pregnancy of unknown location

Answer 9

Beta HCG - repeated after 48 hours

Repeat USS after 1 - 2 weeks

Question 10

When does the beta HCG level indicate a non intrauterine pregnancy

Answer 10

Rise of > 63% after 48 hours

• indicates ectopic to POL

Question 11

When should pregnancy be visible on USS

Answer 11

Beta HCG > 1500 IU/L

Question 12

When is a miscarriage indicated

Answer 12

A fall of the Beta HCG of > 50%

Question 13

Investigation for miscarriage

Answer 13

Repeat Beta HCG

Repeat urine pregnancy test after 2 weeks

Question 14

Management of ectopic pregnancy

Answer 14

Medical emergency

Terminate pregnancy

Question 15

How to terminate a pregnancy

Answer 15

Expectant management - awaiting natural termination

Medical management - methotrexate

Surgical management - salpingectomy or salpingotomy

Question 16

Criteria for expectant management

Answer 16

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

Question 17

Criteria for methotrexate

Answer 17

HCG level must be < 5000 IU / l

Confirmed absence of intrauterine pregnancy on ultrasound

Question 18

How is methotrexate given

Answer 18

Intramuscular injection into a buttock

Question 19

Advice with methotrexate

Answer 19

Not to get pregnant for 3 months following treatment as teratogenic

Question 20

Side effects of methotrexate

Answer 20

• Vaginal bleeding
• Nausea and vomiting
• Abdominal pain
• Stomatitis (inflammation of the mouth)

Question 21

Criteria for surgical management

Answer 21

Pain

Adnexal mass > 35mm

Visible heartbeat

HCG levels > 5000 IU / l

Question 22

First line surgery for an ectopic pregnancy

Answer 22

Laparoscopic salpingectomy - general anaesthetic and removal of the affected fallopian tube with the ectopic pregnancy

Question 23

When is laparoscopic salpingotomy used

Answer 23

For women at increased risk of infertility due to damage of the other tube

Question 24

Laparoscopic salpingotomy

Answer 24

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

Question 25

Anti-rhesus D prophylaxis

Answer 25

Given to rhesus negative women having surgical management of ectopic pregnancy