Ectopic Pregnancy Flashcards
What is ectopic pregnancy?
Occurs when the embryo implants outside the uterine cavity
How common are ectopic pregnancies?
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)
Where do ectopic pregnancies implant?
What is the etiology of ectopic pregnancies?
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
When should an ectopic pregnancy be considered as a diagnosis?
CONSIDER IN ANY WOMAN OF REPRODUCTIVE AGE WITH ABDOMINAL PAIN (diagnosis easily missed)
What are the clinical features of ectopic pregnancy?
Abd pain
PV bleeding
Collapse
Amenorhea
What are the clinical features seen in ectopic pregnancy?
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
What is seen on examination in an ectopic pregnancy?
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)
What investigations are done for an ectopic pregnancy?
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
What is a hetertopic pregnancy?
One normal pregnancy and one ectopic pregnancy
How can ectopic pregnancies be managed subacutely?
Conservatively and mediaclly
What are the features needed to be met for subacute management of ectopic pregnancies?
What is used for medical management of ectopic pregnancies?
Methotrexate
(1mg/kg or 50mg/m2)
What is methotrexate?
Folic acid antagonist: inhibits DNA/RNA synthesis and cell multiplication by inactivating DHFR
What is sensitive to the action of methotrexate?
Rapidly proliferating tissues
How is methotrexate given for ectopic pregnancy?
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
When is methotrexate CI? (4)
Blood dyscrasias
Certain infections
Hepatic or renal disease
Breast feeding /Pregnancy
What are the side effects of methotrexate?
-abdominal pain
-nausea, diarrhoea
-mouth ulcers
Abnormal lfts
How long should someone wait after taking methotrexate for an ectopic before becoming pregnant again?
3 months
When is surgical management needed for an ectopic? (5)
-unable to return for follow-up
-significant pain
-adnexal mass > 35mm
-foetal heart activity
-BHCG > 5000 IU
What are the different types of surgical management of an ectopic?
Laparoscopy> laparotomy
- shorter operative time,
-Less blood loss, adhesion formation, shorted hospital stay, lower cost
-Better or equivalent fertility rates
Salpingostomy-v-salpingectomy
- Salpingostomy -
What are the arguments for and against surgical management of ectopic?
if contralateral tube normal future fertility rates similar for both.
When is laparotomy considered for surgical management? (4)
-Shocked / haemodynamically unstable
-βhCG >15,000IU
-Extensive intra-abdominal adhesions
-Failed conservative or medical mgt.
When is salpingectomy favoured over salpingostomy? (3)
Recurrent ectopic in a treated tube
Ruptured tubal pregnancy
Previous tubal surgery and damage
