Ectopic Pregnancy Flashcards
When does ectopic pregnancy mean?
fetal tissue/embryo implantation outside the uterus or attaches to an abnormal or scarred portion of the uterus
Most common site of ectopic implantation?
Fallopian tube
Mechanism as to why there is implantation of embryo outside the uterus?
Damage to the fallopian tube, secondary to inflammation, causes dysfunction and release of IL-1 (by tubal epithelial cells) and hence retention of oocyte or embryo.
Factors that causes inflammation leading to fallopian tube dysfunction
Toxins, infections, immunologic and hormonal factors
factors that negatively affect the ciliary beat frequency
smoking and infection
Possible sites of implantation by embryo aside from uterus
cervix, uterine cornea, myometrium, ovaries, abdominal cavity
What is heterotopic preganacy
ectopic pregnancy with intrauterine pregnancy
tubal ligation and post-op fallopian tube procedure increase risk of ectopic pregnancy
due to alteration of the native function of the fallopian tube
most common part of fallopian tube in which ectopic pregnancy occurs
ampullary region
What is Cesarean scar pregnancy
migration of the blastocysts into the myometrium due to the residual scarring defect from prior c-section
What is type 1 CS scar pregnancy
implantation at closest proximity to the uterine wall
What is type 2 CS scar pregnancy
implantation closest the bladder wall
Common chief complain in ectopic pregnancy
abdominal pain
Necessary test to diagnose Ectopic pregnancy
Transvaginal ultrasound and hCG level measurement
First marker of intrauterine pregnancy on ultrasound
double decidual sign: small sac eccentrically located within the decidua
What is double decidual sign
a small sac eccentrically located within the decidua
double decidual signs is apparent at what week
5th week
best diagnostic confirmation of ectopic pregnancy
identifying fetal heartbeat outside of the uterine cavity on ultrasound
Safe and effective treatment modalities
Administration of intramuscular methotrexate or performance of laparoscopic surgery
The decision of which modality to pursue is guided by
patient’s clinical picture, laboratory findings, and radiologic imaging
Patients with relatively low hCG levels would benefit from what treatment
single-dose methotrexate protocol
Patients with higher hCG levels would benefit from what treatment
two-dose regimens of methotrexate
Surgical management is necessary when
patients demonstrate any of the following: an indication of intraperitoneal bleeding, symptoms suggestive of ongoing ruptured ectopic mass, or hemodynamically instability
Surgical management including
salpingostomy or salpingectomy
salpingectomy involves
removing the fallopian tube partially or in full.
Salpingostomy, or salpingotomy, involves
removal of the ectopic pregnancy via tubal incision while leaving the fallopian tube in situ
In cases of tubal ectopic pregnancy, contraindications for Methotrexate therapy include the following, EXCEPT:
A. Breastfeeding
B. Thrombocytopenia
C. Migraine headache
D. Intraabdominal hemorrhage
C. Migraine headache
Which of the following would be most closely associated with Methotrexate therapy failure during ectopic pregnancy treatment?
A. Increased parity
B. Ectopic size of 2.5 cm
C. Prior ectopic pregnancy
D. Beta hCG >9,000 mIU/ml
D. Beta hCG >9,000 mIU/ml
Risk factors for ectopic preganacy
- STI, especially by C. trachomatis (CDC, 2007)
- Earlier diagnosis of ectopic pregnancy.
- Failed contraception.
- Tubal sterilization.
- Assisted reproductive technology (ART)
- Tubal surgery (salpingotomy: tubal pregnancy & tuboplasty:
infertility)
TYPES OF ECTOPIC PREGNACY
- Tubal Pregnancy
- Heterotopic Pregnancy
- Cervical Pregnancy
- Ovarian Pregnancy
- Abdominal Pregnancy
- Cesarean Scar Pregnancy (CSP)
Tubal pregnancy pathogenesis
- Transit of fertilized ovum os blocked
- Burrows through the tubal mucosa
- Trophoblasts invade and erode
- Maternal blood vessels are opened
- Expanding conceptus leads to rupture of muscle wall
Most common signs and symptoms
- Pelvic and abdominal pain (95%)
- Vaginal bleeding or spotting (60-80%)
DIAGNOSIS
- Serum beta-hCG (1,000-2,000 mIU/mL with intrauterine
pregnancy) - Serum progesterone: 10-25 ng/ml
- Decrease in hemoglobin and hematocrit
- Culdocentesis
- Ultrasound: complex adnexal mass, fluid in cul-de-sac
- Laparoscopy: Gold standard
Culdocentesis
: aspiration of non-clotting blood
Ultrasound findings
complex adnexal mass, fluid in cul-de-sac
Gold standard for diagnosis
Laparoscopy
Indication for methotrexate
o Pregnancy is <6 weeks
o Tubal mass <3.5 cm
o No cardiac activity
o Serum B-hCG <10-15,000 mIU/ml
Contraindication for methotrexate
o Active bleeding
o Breastfeeding
o Immunodeficiency
o Alcoholism
o Blood dyscrasia
o Liver or renal disease
o Pulmonary disease
when to assume pxt has ectopic pregnancy
early pregnancy, bleeding and pain
how to exclude ectopic pregnancy
ultrasound and labs (best hcg)
Strongest risk factor for ectopic pregnancy
prior ectopic pregnancy
Spielberg Criteria for Ovarian Pregnancy
- The tube on the ipsilateral side is intact
- The ectopic pregnancy occupies the ovary
- The ectopic pregnancy is attached to the uterus by the utero-ovarian ligament
- Ovarian tissue is identified histologically amid placental tissue
Classic triad
Amenorrhea, Abdominal pain, Vaginal bleeding/spotting
Diff diag Ap because
-if exquisite pain on the right lower quadrant
Diff diag pid if
pain and wiggling tenderness
S&S for ruptured ectopic pregnancy
hypotension, tachycardia and signs of peritoneal irritation due to hemoperitoneum
Rupture occurs due to
maximal distention of muscularis
Rupture cause severe hemorrhage due to
close proximity to uterine and ovarian arteries
management for rupture ectopic pregnancy
salpingectomy
MOA: Methotrexate
folic acid antagonist: binds to dihydrofolate reductase which reduces dihydrofolate to tetrahydrofolate (active form of folic acid), leading to arrest in DNA, RNA and protein synthesis of rapidly proliferating tissue such as trophoblasts.
Indication for salpingostomy
Used to remove unruptured pregnancy that is <2 cm in size
Indication for Salpingotomy
Used to remove unruptured pregnancy that is <2 cm in size
Salpingotomy vs Salpingotomy
Same as salpingostomy, except that the incision is closed with
delayed-absorbable suture
Tubal rupture occurs w/in first few weeks is common in
isthmic pregnancies
Level of beta HCG that causes a + preg test
10-20 mIU/mL
Discriminatory level of B HCG
1500 mIU/MI
serum progesterone that exclides ectopic pregnancy
> 25ng/mL
when to use transabdominal ultrasound
at uterine pregnancy at 28 days after ovulation
(+) ectopic pregnancy via culdocentesis
blood collected doesn’t clot
