Ectopic Pregnancy Flashcards
What is an Ectopic Pregnancy?
Pregnancy implanted outside uterus
Where is the most common implantation site of an Ectopic pregnancy?
Fallopian tube
What is the prevalence of Ectopic pregnancies in the UK?
1/80 pregnancies
What are the RF for an Ectopic Pregnancy? (6 things)
- Previous EP
- Previous PID
- Previous of surgery to fallopian tubes
- IUD
- Age
- Smoking
When do the CF of EP normally present?
6-8 weeks gestation
What are the CF of EP? (4 things)
- Pain (lower abd / pelvic)
- Vaginal bleeding
- Amenorrhoea (aka missed period)
- Shoulder pain
What are the CF of EP @ examination? (2 things)
- Lower abd / pelvic tenderness
- Cervical motion tenderness (pain @ moving cervix @ bimanual exam)
What is the difference between Vaginal and Intra-abd bleeding in EP?
- Vaginal: Uterine cavity breakdown bc not enough β-HCG
- Intra-abd: Ruptured EP
How will a pt present with a Ruptured EP?
Haemodynamically unstable
Why might someone with EP present with Shoulder pain?
Blood in peritoneal cavity irritates diaphragm –> referred shoulder pain
What are some differential Dx that present similarly to EP? (6 things)
- Miscarriage
- Ovarian cyst haemorrhage / torsion / rupture
- PID
- UTI
- Appendicitis
- Diverticulitis
What is the first important investigation for sus EP?
Pregnancy test (β-HCG test)
What investigation should be performed if the Pregnancy test in sus EP is positive?
Pelvic US
What should be offered if no pregnancy is seen on the Pelvic US?
Transvaginal US
What is the term used to describe a positive pregnancy test but NO pregnancy seen on US?
Pregnancy of Uknown Location (PUL)
What are the 3 main differentials of PUL?
- Very early intrauterine pregnancy
- Miscarriage
- EP
What investigation should you do for PUL?
Serum β-HCG
What Serum β-HCG levels are considered EP?
1500+ iU
What investigation should be done to confirm the diagnosis of EP when Serum β-HCG levels are 1500+?
Diagnostic laparoscopy
What investigation should be done if Serum β-HCG levels are below 1500 and pt is stable?
Another Serum β-HCG after 48 hours
What are the HCG levels expected to do every 48 hours in a VIABLE pregnancy?
Double every 48 hours
What are the HCG levels expected to do every 48 hours in a Miscarriage?
Halve every 48 hours
What should you do if the HCG levels doesn’t double / halve every 48 hours and was initially below 1500?
Can’t exclude EP so manage accordingly
How could you exclude a differential of UTI in sus EP?
Urinalysis
What are the Mx options for EP? (3 things)
- Expectant (await natural termination)
- Medical (methotrexate)
- Surgical (salpingectomy / salpingotomy)
What are the criteria for Expectant Mx of EP? (6 things)
- Follow up possible to ensure successful termination
- EP needs to be unruptured
- Adnexal mass less than 35mm
- No visible heartbeat
- No significant pain
- HCG level below 1500
What are the criteria for Medical (MTX) management of EP? (2 things)
Same as Expectant except:
- HCG level below 5000
- Confirmed absence of IU pregnancy on US
How does the Methotrexate work for Medical Mx of EP?
MTX = Anti-folate cytotoxic agent –> disrupts Folate dependant cell division of developing foetus
How do you ensure the Methotrexate is working for EP Mx?
Measure HCG levels regularly (supposed to decline by 15+ % by day 5)
What should you do if the HCG levels aren’t declining properly after you Methotrexate EP Mx?
Give repeat dose
What are the Advantages of Medical Mx with MTX for EP? (2 things)
- Avoid surgical complications
- Pt can go home after injection
What are the Side Fx of MTX as Medical Mx for EP? (9 things)
- N+V
- Stomatitis (mouth infamm)
- Abd pain
- Myelosuppression
- Renal dysfunction
- Hepatitis
- Vaginal bleeding
- Teratogenesis
- Failure of Tx
What are the criteria for Surgical Mx of EP? (4 things)
- Pain
- Adnexal mass 35+ mm
- Visible heartbeat
- HCG level 5000+
What is the most common surgical procedure for EP Mx?
Laparoscopic salpingectomy (remove ectopic + tube it’s in)
When would you do a Salpingotomy instead of Salpingectomy for EP Mx? (2 points)
- If other tube is damaged bc infection / disease / surgery
- This is to preserve the EP tube to preserve future fertility
If you do a Salpingotomy instead of Salpingectomy, what should you do you need to do?
- HCG follow up until it reaches below 5
- To ensure no residual trophoblast
What is the disadvantage of doing a Salpingotomy instead of a Salpingectomy for EP Mx?
Risk of recurrent EP in salvaged tube
What are the Advantages of Surgical Mx of EP? (2 things)
- Reassurance that gonna be treated for defo
- High success rate
What are the Disadvantages of Surgical Mx of EP? (2 things)
- Anaesthesia risk
- Damaging nearby structures
- DVT / PE / Haemorrhage / Infection
- Tx failure (salpingotomy)
What do all Rhesus Negative women who receive Surgical Mx for EP need to be offered?
Anti-D prophylaxis
