Ectopic pregnancy

Question 1

What are the ACOG recommendations for the prerequisites for the medical management of an ectopic pregnancy

Answer 1

Viable intrauterine pregnancy excluded
Clinically stable
Minimal pain/bleeding
bHCG <5000 iU ideally <3000
Ectopic diameter <3.5cm
No fetal HR
Women understands return precautions, follow up, failure rate, will attend follow up, has access to transport and phone, lives within 30 mins of hospital

Question 2

Describe one protocol for medical management of ectopic

Answer 2

day 1 - 50mg/m2 IM dose of methotrexate on same day as TV USS, FBC, LFT, U&E and bHCG
Day 4 - bHCG
Day 7 - bHCG + LFT + U&E repeat
Consider repeat dose, or surgical management if levels have not dropped by at least 15% from day 4-7

Question 3

What are the potential complications of medical management with methotrexate?

Answer 3

Failure of treatment
Rupture of ectopic
Potentially teratogenic if becomes pregnant within 3 months
Gastric side effects
LFT derangement/hepatitis
Kidney injury
alopecia

Question 4

What is the mechanism of action of methotrexate?

Answer 4

Folate antagonist - deplete folate necessary for DNA replication
Causes rapidly dividing cells to halt division i.e. the ectopic pregnancy (and GI tract)

Question 5

List 7 surgical options for managing ectopic pregnancies and the indication for each

Answer 5

Salpingotomy - wanting to preserve fertility in the context of contraleteral tube being scarred/damaged
Salpingectomy - most effective treatment for ectopic, if fertility desired should review other tube
Wedge resection - interstitial ectopic
Rudimentary horn excision - Cornual ectopic
Oophorectomy - ovarian ectopic
Suction evacuation - scar ectopic, cervical ectopic if actively bleeding
hysterectomy - last line for uncontrolled haemorrhage

Question 6

what is the frequency of cervical ectopic?

Answer 6

1%

Question 7

how can you differentiate a cervical ectopic pregnancy from a miscarriage?

Answer 7

absence of the sliding sign
in a miscarriage the gestational sac slides against the endocervical canal
blood flow around the gestational sac using colour doppler

Question 8

what is the recommended management of a cervical ectopic?

Answer 8

medical management with methotrexate

surgical management with D&C associated with high rates of complication

Question 9

what percentage of ectopic pregnancies are in the tube?

Answer 9

96%

Question 10

In order what are the most common ectopic pregnancy sites?

Answer 10

• tubal (96%)
• interstitial
• cervical
• ovarian

Question 11

what are the USS feature of a C/S scar ectopic?

Answer 11

• empty uterine cavity
• gestational sac within the old CS scar
• thin layer of myometrium between gestational sac and bladder
• negative sliding organ sign

Question 12

What are the USS features of a cervical ectopic?

Answer 12

• empty uterus
• barrel shaped uterus
• gestational sac below the level of internal os
• negative sliding sign - in miscarriage the gestational sac slides against the endocervical canal however ectopic is fixed

Question 13

what is the incidence of c/s scar ectopic?

Answer 13

1:2500 incidence increasing

Question 14

what are the two types of CS scar ectopic?

Answer 14

• type 1 endogenic - grow into uterine cavity, potential to reach viable gestational age with associated risk of massive from placental site
• type 2 exogenic - progression deeper toward serosal surface of myometrium –> toward the bladder, risk of 1st trimester rupture and haemorrhage

Question 15

what is the