Ectopic Pregnancy Flashcards
What are the causes of ectopic tubal pregnancy?
1- congenital hypopolasia of the tube, congenital accessory tubal ostia, or tubal diverticula
2- previous tubal surgery
3- chronic salpingitis
4- endometriosis
5- altered tube motility -> progestogen-only pills, morning after, IUCD
6- broad ligament/pelvic masses
7- transperitoneal migration of the ovum
8- rapid development of the trophoblast or excessive decidual reaction in tubal mucosa
What are the sites of implantation for ectopic pregnancies?
1- most common -> ampulla
2- isthmus or interstitial
3- least common -> fimbria
What are the causes of disturbance of ectopic pregnancy?
1- decidua defective & unable to resist invasion by growing trophoblast
2- thin muscle wall unable to stretch
3- narrow tubal lumen
What are the timings of rupture of tubal pregnancy?
- isthmus -> 2 weeks
- ampulla -> 10 - 12 weeks
- interstitial part -> up to 16 weeks but may be fatal if it ruptures due to increased vascularity
What pathology will result in case of rupture of ectopic gestational sac towards the lumen of the fallopian tube?
1- hematosalpinx
2- tubal mole
3- tubal abortion
4- peritubal hematoma, pelvic hematocele, diffuse intra-peritoneal hemorrhage
What are the causes of rupture of ectopic gestational sac towards the outer surface of the fallopian tube?
- spontaneously
- coitus
- bimanual pelvic examination
What pathology will result in case of rupture of ectopic gestational sac towards the roof of the fallopian tube?
- paratubal hematoma & pelvic hematocele
- diffuse intra-peritoneal hemorrhage
- secondary abdominal pregnancy
What pathology will result in case of rupture of ectopic gestational sac towards the floor of the fallopian tube?
broad ligament hematoma
What are the effects of ectopic pregnancy on the uterus?
- becomes soft & slightly enlarged up to 6-8 weeks (due to hormones by corpus luteum))
- after disturbance -> shedding of decidua -> vaginal bleeding
- Arias-Stella reaction
What is the clinical picture of ectopic pregnancy?
SYMPTOMS
- PAIN
- vaginal bleeding: shedding of decidua
- fainting: due to hypovolemia & peritoneal irritation
SIGNS
- hypovolemia: pallor, rapid weak pulse, low blood pressure
- breast signs of pregnancy
VAGINAL EXAMINATION
- Chadwick’s sign: bluish soft moist vagina
- Goodwell’s sign: Soft cervix
- Jumping sign: pain on moving cervix
- tenderness on posterior or lateral fornices
- bimanual examination: irregular tender adnexal mass
What investigations should be preformed for diagnosis of ectopic pregnancy?
1- urinary pregnancy test: if negative does not exclude pregnancy
2- serum B-hCG: if negative excludes pregnancy
- if no doubling after 48hours -> abnormal pregnancy
3- Ultrasound -> empty endometrial cavity
-> thick endometrial lining
-> tubal or adnexal mass
-> blood in Douglas pouch
What is the discriminatory zone for diagnosis of ectopic pregnancy by B-hCG & US?
- abdominal ultrasound shows gestational sac when B-hCG is 6500 or >
- vaginal ultrasound shows gestational sac when B-hCG is 2000 or >
if no gestational sac is found at these numbers -> ectopic pregnancy is diagnosed
When can laparoscopy be used in ectopic pregnancy?
diagnostic & therapeutic in undisturbed & early disturbed stable cases
What lab investigations are done in case of ectopic pregnancy?
1- CBC: anemia, exclude inflammation
2- Urine analysis: exclude pyelitis
3- D&C biopsy: decidual reaction & absence of chorionic villi & fetal tissue
4- Culdocentesis: blood in douglas pouch
5- Serum progesterone level: <25 ng/ml
How is an ectopic pregnancy managed if early & undisturbed & patient is stable?
CONSERVATIVE
rest & observation
- if B-hCG level are falling -> pregnancy is aborting
- if B-hCG levels are not falling -> methotrexate
- if medical fails -> laparoscopy
- GIVE ANTI-D IF RH-ive & husband is +ive (300ug IM)
advise women to
- avoid sex
- maintain ample fluid intake
- use reliable contraception for 3 months after methotrexate
- follow up B-hCG twice weekly, transvaginal US weekly till B-hCG becomes 20mlU/ml
