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MRCOG - Part 2 > Ectopic Pregnancy > Flashcards

Ectopic Pregnancy Flashcards

1
Q

What is ectopic pregnancy

A

Pregnancy outside of uterine cavity

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2
Q

Incidence of ectopic pregnancy

A

11/1000

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3
Q

How many presenting to EPU have ectopic pregnancy

A

2-3%

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4
Q

Risk factors of ectopic pregnancy

A

ART
TUBAL DAMAGE
PREVIOUS ECTOPIC
PREVIOUS INFECTION like PID
PREVIOUS SURGERY
SMOKING

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5
Q

Best diagnostic tool for ectopic pregnancy

A

TVS
Laparoscopy is no longer gold standard

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6
Q

In diagnosing of Ectopic pregnancy, Rate of false negative laparoscopies

A

3 - 4.5%

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7
Q

US findings of tubal ectopic

A

Empty uterine cavity
Presence of sac in adnexa separate form ovary 50-60%
Extrauterine gest sac 20-40-%
G sac with yolk sac and fetal pole with or without cardiac activity 15-20%
Pseudosac
Echogenic fluid in POD 28-36%

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8
Q

what does ehcoegenic fluid signify

A

Haemopertonuem
Majority Cases: blood from fibril end of the tube meaning tubal abortion
In others: ruptured tubal pregnancy

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9
Q

Which blood investigation done in diagnosis of ectopic pregnancy

A

Beta hcg
In all types of ectopic preg., bhcg has only prognostic value, no diagnostic value.

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10
Q

Ways you can manage a tubal Ectopic?

A

Expectant
Medical
Surgical

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11
Q

Criteria of Expectant management

A

No pain
hemodynamically stable
no hemoperitoneum
sac <30mm
no cardiac activity
bhcg <1500
woman’s consent
ability to f/up

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12
Q

When is expectant mx discontinued?

A
  • women withdraw consent
  • significant pain
  • hemodynamically unstable
  • rising bhcg to >2000
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13
Q

In expectant mx, till what level of bhcg women followed up

A

less than 20

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14
Q

Success rate of expectant management

A

57-100% depending on initial bhcg level.
Overall 72%

If bhcg <1000 = 80-90%

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15
Q

Criteria of medical management

A

No pain
hemodynamically stable
no hemoperitoneum
sac <35 mm
no cardiac activity
bhcg 1500-5000
woman’s consent
ability to f/up
no IU pregnancy
No sensitivity to MTX

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16
Q

How do u f/up post MTX

A

BhCG on day 4 & 7
If decreased by >15% -> weekly levels till <15
if decreases by <15% –> reevaluate by US

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17
Q

Percaution along w/ MTX

A

Avoid Alcohol and Folate
Baseline Inv.: CBC, BG, urine, LFT, U&E

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18
Q

MTX common side effects and adverse effects

A

Common:
- Mild elevated LFTs
- Stomatitis
- Bloating, excessive flatulence

Adverse:
- GI ulcers
- Pneumonitis
-Pulmonary fibrosis
- Liver cirrhosis
- Renal Failure
- Bone Marrow suppression

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19
Q

MTX contraindications

A

Hemodynamic instability
presence of IU preg.
Breastfeeding
If unable to comply with f/up
Sensitivity to MTX
Chronic liver disease
Pre existing blood dyscrasia
Activity pulmonary disease
Immunodeficiency
Peptic ulcer disease

20
Q

Which surgery is done for tubal ectopic

A
  • Salpingotomy (if fertility reducing factors= preferred)
  • Salpingectomy (preferred)

either laparoscopic (preferred) or open

21
Q

Success rate of medical mx

A

65-95%

22
Q

rate f persistent trophoblast after salpingectomy or salpingotomy

A

Salpingectomy <1%
Salpingotomy 7% - range of 3.9 -11%

23
Q

If no fertility reducing factors, repeat ectopic after surgery

A

Salpingectomy 5%
Salpingotomy 8%

Rates of intrauterine pregnancy >90% in both

24
Q

If fertility reducing factors, rate of IU preg after surgery

A

Salpingectomy 75%
Salpingotomy 40%

25
Q

US criteria for diagnosing CX preg

A
  1. Empty uterine cavity
  2. barrel shaped CX
  3. Gsac present below the level of int. cx os
  4. absence of sliding sign
  5. blood flow around the gsac using color doppler
26
Q

Incidence of cx pregnancy

A

<1% of all ectopic pregnancies

27
Q

Does Cx preg. managed medically or surgically

A

Medical - 1st line
Surgical only when life threatening bleeding

28
Q

Criteria for risk of failure of medical mx of cx pregnancy

A

Gsac >9weeks
Cardiac activity
CRL >10 mm
BhcG >10000

29
Q

Prevelrnce of Caesarean scar pregnancy

A

1 in 2000

30
Q

Inv. of choice in diagnosis of CS pregnancy

A

U/S
if non conclusive: MRI

31
Q

US diagnostic criteria of CS ectopic preg.

A
  1. Empty uterine cavity
  2. Gsac or sold mass of trophoblast located anteriorly at the level of int. os embedded at site of previous lower uterine segment CS scar
  3. thin or absent layer of myometrium between Gsac and bladder
  4. Empty endocervical canal
32
Q

Management of CS scar ectopic

A

Medical: MTX (local or sys.)
associated w/ high risk hmge d.t. degeneration of highly vascular placenta

Surgical: Suction evacuation or open, laparoscopic or hysteroscopic excision of scar pregnancy w/ repair

33
Q

Can expectant mx be done in CS scar pregnancy?

A

If small, non viable scar pregnancy.
If pregnancy is partially implanted into the scar and grows into uterine cavity. the woman must be counseled of risks, huge, morbidly adherent placentation, and she declined termination of pregnancy

34
Q

Incidence of interstitial pregnancy

A

1 - 6.3% of all ectopic

35
Q

US criteria for interstitial pregnancy?

A
  • empty uterine cavity
  • products of conception/gsac located laterally in interstitial part of the tube and surrounded by <5mm of myometrium in all imaging planes
  • The interstitial line sign, which is a thin echogenic line extending from the central uterine cavity echo to the periphery of the interstitial sac.
36
Q

Mx of interstitial pregnancy

A

surgical by cornual resection
Pharma: MTX

37
Q

Incidence of Cornual Pregnancy

A

1 in 76000

38
Q

US of cornual preg.

A
  • Visualization of a single interstitial portion of Fallopian tube in the main uterine body.
  • GSac/product of conception seen mobile and separate from the uterus and completely surrounded by myometrium
  • A vascular pedicle adjoining the gestational sac to the unicornuate uterus
39
Q

Mx of Cornual Preg.

A

Excision of the rudimentary horn via laparoscopy or laparotomy (to avoid recurrence)

40
Q

DD of ovarian pregnancy

A
  • Corpus luteal cyst
  • tubal ectopic pregnancy stuck to ovary
  • 2nd corpus luteum
  • ovarian germ cell tumor
41
Q

How we confirm diagnosis of Ovarian pregnancy

A

Surgical and histology

42
Q

Mx of Ovarian Pregnancy

A

Surgical: enucleation or wedge resection.
If Ovarian pathology or excessive bleeding: Oophorectomy

Medical: If high risk for surgery or if persistently raised BhCG or persistent trophoblast.

43
Q

Diagnosis of early and late abdominal pregnancy

A

US & MRI respectively

44
Q

US criteria of abdominal pregnancy

A
  • no intrauterine Gsac
  • no evident dilated tube or complex adnexal mass
  • Gestational cavity surrounded by loops of bowel & separated from them by peritoneum
  • a wide mobility similar to fluctuation of the sac particularly evident w/ pressure of trasvagifnal probe towards the posterior cut-de-sac
45
Q

Mx of Abdominal Pregnancy

A

Early: laparoscopic removal
LAte: Laparotomy and manage

46
Q

when will you suspect heterotopic pregnancy?

A

Heterotopic pregnancy should be considered in all women presenting after assisted reproductive technologies, in women with an intrauterine pregnancy complaining of persistent pelvic pain and in those women with a persistently raised b-hCG level following miscarriage or termination of pregnancy.

47
Q

Management of Heterotopic preg.

A

Medical: If intrauterine is non viable
Surgical: removal in both stable and unstable patients
Expectant: if hetero is nonviable

MRCOG - Part 2 (44 decks)

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