Ectopic pregnancy Flashcards
Define
Fertilised ovum implanting and maturing OUTSIDE of the uterine endometrial cavity
The most common site being the fallopian tube (97%).
- Within the fallopian tube, it most commonly occurs at the AMPULLA(73%)
- It can also implant into the isthmus, fimbria and interstitium and cornua
- Ectopic rupture is more likely to occur at the isthmus
Other sites:
- Ovary
- Abdomen
- Cervix (<1%)
Interstitial part (at the junction of the uterus and fallopian tube)
Aetiology
Damaged tubes (infection (PID), surgery, endometriosis):
- PID
- Previous tubal surgery
- IVF
- Previous ectopic (10% recurrence)
- Pregnancy with IUD/IUS Depo-Provera injection
The 2 broad categories of conditions that lead to ectopic pregnancy are:
- Risk factors or conditions that lead to tubal epithelial damage
- Conditions that predispose the embryo to premature implantation
Pathophysiology
Migration difficulty of the oocyte is often associated with abnormal fallopian tube anatomy
E.g. chronic salpingitis, salpingitis isthmica nodosa, tubal surgery
As the ectopic grows, the outer layer of the fallopian tube stretches- this ultimately leads to rupture and bleeding
Commonly occurs due to PID or STIs
If ectopic occurs in ampulla, it eventually runs out of space → slowly stretches nerve fibres of walls of fallopian tube → lower abdominal pain
Eventually, expansion can damage the ampulla wall → rupture of the fallopian tube → can lead to massive haemorrhaging into abdominal cavity → blood irritates peritoneum → referred pain to shoulder
Can also get signs of hypovolaemic shock due to bleeding
- If ectopic is in fallopian tube, pressure increases as tube stretches around 6-8 weeks into pregnancy, but if ectopic occurs somewhere with capacity to expand (e.g. ovary) then pain and bleeding may not occur until several weeks later
Risk factors
- Previous ectopic pregnancy
- Age > 35 years
- Previous tubal sterilisation surgery/ damage to fallopian tubes/ fallopian tube surgery
- History of infertility
- Previous genital or pelvic infections (PID)
- Smoking
- Multiple sexual partners (due to risk of STI and PID)
- IVF/ Assisted reproductive techniques
- LNG-IUS, copper IUD
- Progesterone contraceptive slows down cilia in tube increasing chance of ectopic
- Endometriosis
2 types of ectopic
Stable ectopic
- Missed menstrual period (LMP usually 6-8 weeks ago)
- abdominal pain
- and/or vaginal bleeding in early pregnancy
- May have adnexal mass
Unstable ruptured ectopic
- Abdominal pain
- PV Bleeding
- Shoulder tip pain
- Rupture of ectopic causes haemoperitoneum → peritonitis → irritates diaphragm → shoulder tip pain via phrenic nerve (~20% of cases)
- Rectal pressure
- Dizziness/fainting/syncope
Symptoms
COLLAPSE
- Abdominal pain - one sided and lower more likely
- Amenorrhoea 4-10 weeks, ± PV bleeding (scanty dark blood)
- Vaginal bleeding +/- clots
- This is due to irritation from intraperitoneal bleeding
- This is a possible warning sign of RUPTURE
- Blood in recesses irritates surrounding viscera
- Dizziness (if ruptured -> present with circulatory collapse)
- Shoulder-tip pain
- Referred pain from the irritation of the diaphragm
- Sign of haemoperitoneum - warning sign of RUPTURE
- This pain is there all the time and may be worse when you are lying down
- It is not helped by movement and may not be relieved by painkillers
On examination
- Abdominal and/or pelvic tenderness
- Cervical motion tenderness- helps differentiate between appendicitis and ectopic
- Haemodynamic instability- High pulse + low BP
- It is ok to do a bimanual!
On examination:
Abdomen – rebound tenderness ± guarding
Vaginal – cervical excitation, adnexal tenderness ± mass
Investigations
ABCDE
Basic observations
Urine or serum pregnancy test
Urine dipstick
Bloods
- Serial serum hCG - done in secondary care!
- hCG should double every 48 hours in a normal pregnancy.
- The rise in ectopics are usually suboptimal
- Serial hCG measurements 48 hours apart may show this
FBC
U&Es - kidney stones
Group and Save (or Crossmatch if severely compromised)
TVUSS/ Transabdominal USS
- Would see empty uterus with adnexal mass
DDx
- Miscarriage - less pain, more bleeding
- Molar pregnancy
- Implantation bleed
- Ovarian torsion
- Implantation bleed
- Subchorionic haemorrhage
- Appendicitis
- Kidney stones
- PID
- Trauma
Management
First step on confirming an early-pregnancy-related emergency is to call the gynaecology on-call
o Expectant – only permissible in stable, asymptomatic patient with falling levels of b-hCG (tubal abortion)
- Size <30mm
- Asymptomatic
- Serum hCG <200 IU/L and declining
- No foetal HR
o Medical – x1 IM methotrexate injection can be done if…
Indications:
- Stable
- Asymptomatic
- No blood in pouch of Douglas
- Normal LFTs / U&Es
- bHCG <3,000 IU/L
- Ectopic <35mm / no FH detected
Expectations:
- Go home -> come back for repeat blood tests
- No intercourse for 3 months
- Don’t drink alcohol
- Avoid excessive sun exposure
SEs: pain, nausea and diarrhoea (first few days)
o Surgery – laparoscopic salpingectomy
Indications:
- Significant pain
- Adnexal mass >35mm
- Ectopic with foetal HR
- bhCG >5,000IU/L
Salpingostomy can be used if bleeding is minimal and occlusion is viable to be removed (i.e. at fimbriae) and the patient only has one viable tube left (as high future ectopic risk)
· “-otomy” = cutting into -> Not much difference in fertility!
· “-ostomy” = cutting into and removing waste -> fertility required (high future ectopic risk)
· “-ectomy” = removal of an (part of an) organ -> fertility not too important
Anti-D prophylaxis required (no Kleihauer needed)
- No anti-D if… sole medical management, threatened or complete miscarriage or PUL
- Copper IUD should not be used if you’ve had a laparoscopic salpingectomy
Haemodynamically unstable management
Complications
Ruptured ectopic –> shock
Adverse effects associated with methotrexate
- Hepatotoxicity, nephrotoxicity, pulmonary toxicity
- Myelosuppression
- GI effects- N + V
- Stomatitis
- Neurological problems
- Fever
Persistent trophoblast
Infection and Damage to surrounding organs or vasculature resulting from surgical intervention
Recurrent ectopic pregnancy
Prognosis
Treatments are highly successful (82-92%)
Rate of recurrent ectopic pregnancy is 5-20% but rises to > 30% in women with 2 consecutive ectopic pregnancies
The chances of having a successful pregnancy in the future are good. Even if you have only one fallopian tube, your chances of conceiving are only slightly reduced.
For most women an ectopic pregnancy is a ‘one-off’ event.
If you already have only one fallopian tube or your other tube does not look healthy, your chances of getting pregnant are already affected.
PACES
DO NOT SAY BABY/ FOETUS - REFER TO IT AS PREGNANCY TISSUE
Setting up the conversation:
- From the examinations and the tests we have done, we have come to a diagnosis for the problem you have been experiencing.
- I’m afraid it’s not good news, would you like anyone to be present with us while I talk to you about the diagnosis?
- Are you comfortable having the conversation here right now?
Diagnosis:
- The cause of your symptoms is something called an Ectopic Pregnancy
- Do you know what an ectopic pregnancy is?
Briefly explain what an ectopic pregnancy is:
- An ectopic is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes (tube connecting the ovaries to the womb)
- In the case of an ectopic, the pregnancy will NOT develop into a baby and can put your health at risk if the pregnancy continues
- Unfortunately, the pregnancy cannot be saved and must be removed in order to keep you safe
- Take as much time as you need to process this information”
- “Do you have any questions at all? What are your thoughts?”
Explain to the patient what the next steps are:
- In order to treat this, we have 3 options available but considering the results from your blood tests and scans, the best treatment option is via surgery as soon as possible.
Explanation of Salpingectomy and Salpingotomy
Salpingectomy
- This is a keyhole surgery where you will be put to sleep and the fertilised egg along with the affected tube will be removed.
- After the procedure, you will be given an injection to protect the baby in future pregnancies.
Salpingotomy
- This is also a keyhole surgery where you will be put to sleep but the fallopian tube is opened, the fertilised egg is removed and the tube is closed up after this.
- Once again, after the procedure, you will be given an injection to protect the baby in future pregnancies.
Risks
- As this is a surgical procedure, there are risks involved, which will be explained to you in detail by the Consultant who is carrying out the procedure and the anesthetists.
- Bleeding, infection, damage to other organs, pain after the procedure
- As the salpingectomy is a process where one of your tubes are removed, it does reduce the chance of you conceiving in the future, but we have found that approximately 65% of women achieve a successful pregnancy within 18 months of an ectopic
- There is also a risk of you experiencing another ectopic pregnancy of around 10-20%.
Advice for the patient:
- We will be giving you some fluids via a tube that sits in your vein called a cannula
- You should also not eat anything from now on until the procedure, you may take sips of water.
- There are support groups available for couples affected by loss of a pregnancy e.g. the Ectopic Pregnancy Trust
- If you are trying for another baby: should wait until at least 2 periods after treatment before trying to allow body to recover
- Sexual intercourse should be avoided during treatment
- Avoid conceiving for 3 months after methotrexate because of risk of teratogenicity
- Avoid alcohol and prolonged exposure to sunlight during treatment
