Ectopic pregnancy Flashcards
Define ectopic pregnancy
Implantation of the pregnancy outside of the uterine cavity e.g. fallopian tube, abdominal cavity, caesarean scars
What are the risk factors for ectopic pregnancy
Previous ectopic pregnancy
Previous caesarean
Previous pelvic or tubal surgery
Fibroids
Pelvic inflammatory disease
Endometriosis
Assisted conception e.g. IVF
Smoking
Advance maternal age
Falling pregnant with IUS/IUD in situ
What is the most common site for ectopic pregnancy implantation
98% implant in the fallopian tube
What is the incidence of ectopic pregnancies
1 in 80 pregnancies are ectopic
What is a heterotopic pregnancy
simultaneously development of two pregnancies, one within and one outside the uterine cavity. IVF is a risk factor if multiple embryos are transferred.
What are the symptoms of ectopic pregnancy
(6-8 weeks after LMP)
Lower abdominal/IF pain, constant
PV bleeding, dark brown, less than period
Positive pregnancy test
Missed period/amenorrhoea
Passing of tissue/discharge/clot]
± breast tenderness, diarrhoea, N&V, dizziness, syncope, shoulder tip pain (peritonitis)
What are the signs of ectopic pregnancy
Abdominal
- Tenderness, Rebound tenderness
- Peritoneal signs
- Pallor
- Abdominal distension
Pelvic - Do not palpate for an adnexal or pelvic mass as this may increase the risk of rupture of an ectopic pregnancy if present.
- Pelvic tenderness
- Adnexal tenderness
- Cervical motion tenderness
- Enlarged uterus
What are the differentials for ectopic pregnancy
Miscarriage
Early VIUP
Appendicits
Ovarian torsion
Molar pregnancy
Rupture ovarian cyst
UTI
Fibroid degeneration
PID
What investigations should be done for an ectopic pregnancy
- A-E assessment
Bedside: urine pregnancy test, urinalysis
Bloods: beta-hCG (levels plateau or not have as marked an increase as normal pregnancy), FBC, CRP, progesterone, G&S
Other:
- TVUSS: Adnexal mass moving separate to the ovary | (GS/YS/Foetal pole) | Bagel sign | Empty uterus/pseudo-sac | Free fluid in POD/peritoneal cavity
- Abdo USS: exclude Appendicitis
How does the level of hCG on serial measurement indicate diagnosis
Likely IUP: Rise more than double (>63%) every 48h
Likely ectopic: 50% decline to 63% rise
Failing pregnancy: >50% decline
How do progesterone levels indicate diagnosis
Likely IUP: >60
Likely ectopic: 26-60 (especially if HCG is also high)
Failing pregnancy: <20
What is the management for ectopic pregnancy
- A-E assessment (instability → admit to emergency)
- Confirm PUL: beta-hCG, location on USS
- Refer to EPAU for serial beta-hCG levels
- Senior review and USS
- Consider anti-D for surgical management
Expectant, medical, or surgical management
What is the expectant management for ectopic pregnancy
Indicated when HCG <1000
Serum hCG levels monitored until levels are undetectable (<15 Monitored every 48 hours until there is a repeated fall in level, then once weekly until levels are undetectable
What is the medical management for ectopic pregnancy
IM methotrexate (folate antagonist), dose based on patient’s surface area
Levels are recorded weekly until undetectable
Will need contraception for 3 months after taking methotrexate due to teratogenicity
Repeat beta-hCG on days 4 and 7
- If b-hCG is only falling by <15% on days 4-7, another methotrexate dose may be required
What is the criteria for medical management
No significant pain.
An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
Serum hCG level less than 1500 IU/L.
No intrauterine pregnancy (as confirmed on an ultrasound scan)
No foetal cardiac activity
No haemoperitoneum on TVUSS
Fully understands safety netting
Close proximity to hospital and patient will comply with follow up
