Ectopic Pregnancy

Question 1

What is ectopic pregnancy?

Answer 1

Occurs when the embryo implants outside the uterine cavity

Question 2

How common are ectopic pregnancies?

Answer 2

1 in 67 pregnancies (14.8 per 1,000 maternities)
> with advanced maternal age and lower SEC

Mortality rate 16.9/100, 000 ectopics (leading cause of maternal death in the first trimester)

Question 3

Where do ectopic pregnancies implant?

Answer 3

Question 4

What is the etiology of ectopic pregnancies?

Answer 4

Not always a reason evident (in up to a third of patients)

Damaged tubes
-Previous ectopic
-PID
-Pelvic surgery
-endometriosis
IUCD (1/2 of pregnancies with IUS are ectopic)
Assisted conception
Smoking

Question 5

When should an ectopic pregnancy be considered as a diagnosis?

Answer 5

CONSIDER IN ANY WOMAN OF REPRODUCTIVE AGE WITH ABDOMINAL PAIN (diagnosis easily missed)

Question 6

What are the clinical features of ectopic pregnancy?

Answer 6

Abd pain

PV bleeding

Collapse

Amenorhea

Question 7

What are the clinical features seen in ectopic pregnancy?

Answer 7

Abdominal pain: lower abdominal. Unilateral. Initially colicky then constant. ? Shoulder tip pain
Vaginal bleeding: scanty dark
Amenorrhoea: 4-10 wks (6-8). So need to ask about LMP, menstrual cycle, sexual activity, possibility of pregnancy
Collapse

Also possible diarrhoea and vomiting due to peritoneal irritation

Question 8

What is seen on examination in an ectopic pregnancy?

Answer 8

Vitals: HR, BP, temp (iMEWs)

Abdominal: (unilateral) Tenderness, +/- Rebound

Pelvic:
Cervical excitation (chandelier sign)
Closed os
Small uterus for gestational age
Adnexal tenderness (unilateral) +/- mass (haem)

Question 9

What investigations are done for an ectopic pregnancy?

Answer 9

Initial: urinary pregnancy test
Ultrasound (TVUS)
-Visualise Ectopic (non-haemogenous adnexal mass , or gestational sac (+/-pole or heartbeat or clot/free fluid in adnexa)
or PUL (pregnancy of undetermined location)
BHCG measurements
(if nil on u/s)
- One BHCG > 1000-1500 then should see IUP
- If < 1500 +uterus empty. Serial Quantative measurements
> 63% at 48hr – IUP
< 63% at 48hrs – Non-viable IUP or ectopic

Laparoscopy

Question 10

What is a hetertopic pregnancy?

Answer 10

One normal pregnancy and one ectopic pregnancy

Question 11

How can ectopic pregnancies be managed subacutely?

Answer 11

Conservatively and mediaclly

Question 12

What are the features needed to be met for subacute management of ectopic pregnancies?

Answer 12

Question 13

What is used for medical management of ectopic pregnancies?

Answer 13

Methotrexate
(1mg/kg or 50mg/m2)

Question 14

What is methotrexate?

Answer 14

Folic acid antagonist: inhibits DNA/RNA synthesis and cell multiplication by inactivating DHFR

Question 15

What is sensitive to the action of methotrexate?

Answer 15

Rapidly proliferating tissues

Question 16

How is methotrexate given for ectopic pregnancy?

Answer 16

IM once off dose: recheck HCG at day 4, 7 and weekly til non-pregnant

If less than 15% reduction between days 4 and 7 check rescan and consider second dose

Question 17

When is methotrexate CI? (4)

Answer 17

Blood dyscrasias
Certain infections
Hepatic or renal disease
Breast feeding /Pregnancy

Question 18

What are the side effects of methotrexate?

Answer 18

-abdominal pain
-nausea, diarrhoea
-mouth ulcers
Abnormal lfts

Question 19

How long should someone wait after taking methotrexate for an ectopic before becoming pregnant again?

Answer 19

3 months

Question 20

When is surgical management needed for an ectopic? (5)

Answer 20

-unable to return for follow-up
-significant pain
-adnexal mass > 35mm
-foetal heart activity
-BHCG > 5000 IU

Question 21

What are the different types of surgical management of an ectopic?

Answer 21

Laparoscopy> laparotomy
- shorter operative time,
-Less blood loss, adhesion formation, shorted hospital stay, lower cost
-Better or equivalent fertility rates

Salpingostomy-v-salpingectomy
- Salpingostomy -

Question 22

What are the arguments for and against surgical management of ectopic?

Answer 22

if contralateral tube normal future fertility rates similar for both.

Question 23

When is laparotomy considered for surgical management? (4)

Answer 23

-Shocked / haemodynamically unstable
-βhCG >15,000IU
-Extensive intra-abdominal adhesions
-Failed conservative or medical mgt.

Question 24

When is salpingectomy favoured over salpingostomy? (3)

Answer 24

Recurrent ectopic in a treated tube
Ruptured tubal pregnancy
Previous tubal surgery and damage

Question 25

What follow up do ecoptic pregnancies need?

Answer 25

If treated with salpingostomy/medical/conservative mx
-> serial hCG until <20 IU/ml
(NICE guidelines advise urinary pregnancy test at 3 wks if salpingectomy)

Bereavement counselling : lost baby, life threatening condition, lower fertility. (3 Ls)

-> 70% future successful pregnancy
-> 10% future ectopic (1 ectopic), 25% ( 2 or more ectopics)

Question 26

Where are other sites of ectopics?

Answer 26

Ovarian: often hard on ultrasound to differentiate from a haemorrhagic cyst. Optimum management removal of ectopic and preservation of ovary.

Cervical: Sac distal to closed internal os. ? Combine vasoconstricting agent, with sutures and currettage

Abdominal

Most common POD.

Question 27

What are primary ectopics?

Answer 27

Usually present in first trimester

Question 28

What are secondary ectopics?

Answer 28

Following EP rupture - can be more advanced

Question 29

An increase of > 63% in serum BHCG over 48hrs is indicative of an ectopic pregnancy

True/False

Answer 29

False - indicates viable IUP

Question 30

Endometriosis is a risk factor for ectopic pregnancy

True/False

Answer 30

True

Question 31

Non-invasive diagnostic algorithms (using a combination of TVUS, serum HCG and serum progesterone) are capable of diagnosing up to 75% of all ectopic pregnancies.

True/false

Answer 31

False actually is 95-98%