Ectopic pregnancy Flashcards
What is an ectopic pregnancy?
An ectopic pregnancy is when a pregnancy is implanted outside the uterus
What is the most common site for an ectopic pregnancy?
The ampulla of the fallopian tube
What are the other sites an ectopic pregnancy can implant?
- cornual region (entrance to fallopian tube)
- ovary
- cervix
- abdomen
What risk factors can increase the chance of ectopic pregnancy?
- prev ectopic pregnancy
- prev PID
- prev surgery to fallopian tubes
- intrauterine devices
- older age
- smoking
When does an ectopic pregnancy typically present with symptoms?
around 6-8 weeks gestation
What are the classic symptoms and features of an ectopic pregnancy?
- missed period
- constant lower abdo pain in the right or left iliac fossa
- vaginal bleeding
- lower abdo or pelvic pain
- cervical motion tenderness (pain when moving cervix in bimanual exam)
- syncope/dizziness
- shoulder tip pain –> peritonitis
What is the gold standard investigation for an ectopic pregnancy?
-transvaginal US –> a gestational sac containing yolk sack or foetal pole may be seen in a fallopian tube
What is a mass containing an empty gestational sac referred to?
-blob sign/ bagel sign/ tubal ring sign
How do you differentiate a tubal ectopic pregnancy mass from a corpus luteum?
tubal ectopic pregnancy moves seperate to the ovary while corpus luteum will move with the ovary
What are features that may indicate ectopic pregnancy in an US scan?
- empty uterus
- fluid in uterus which may be mistaken as a gestational sac (pseudogestational sac)
What is a pregnancy of unknown location PUL?
-when a woman has a positive pregnancy test and no evidence of pregnancy is seen on the US scan
How does serum HCG differ in an intrauterine pregnancy and a miscarriage/ectopic pregnancy?
-In IU pregnancy the hcg will double every 48 hours while in ectopic/miscarriage it will not
How is a PUL managed?
- after US scan confirms no evidence of pregnancy, hCG levels repeated after 48 hrs
- if they rise >63% this likely indicates and IU pregnancy and a repeat US scan is needed after 1-2 weeks (pregnancy should be visible on US when hcg>1500)
- if rise <63% this likely indicates ectopic pregnancy and pt needs close monitoring
- if they fall >50% this likely indicates miscarriage and urine pregnancy test should be performed 2 weeks after to confirm miscarriage is complete
- monitoring symptom changes is more important than hCG level
What needs to be performed in all women presenting with abdo/pelvic pain that can be caused by ectopic pregnancy?
-pregnancy test
If a women presenting with pelvic pain/tenderness has a positive pregnancy test what should you do?
-refer to early pregnancy unit/gynae service
What is the general treatment for all ectopic pregnancies?
Termination of pregnancy
What are the three options for terminating an ectopic pregnancy?
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- surgery ( salpingectomy or salpingotomy)
What is the criteria to be viable for expectant management in ectopic pregnancy?
- follow up needs to be possible to ensure successful termination
- needs to be unruptured
- adnexal mass < 35mm
- no visible heartbeat
- no significant pain/symptoms
- HCG level <1500 IU/L
What should be closely monitored in expectant management?
- HCG levels
- symptom changes
What is the criteria to be viable for medical management with methotrexate in ectopic?
- HCG level must be <5000 IU/l
- confirmed absence of IU pregnancy on US
How is methotrexate given and how does it work to terminate pregnancy?
- given IM into buttock
- highly teratogenic and so halts progress of pregnancy and results in spontaneous miscarraige
What advice should be given to women on methotrexate?
-advised to not get pregnant for 3 moths following treatment
What are common side effects of methotrexate?
- vaginal bleeding
- nausea and vomiting
- abdo pain
- stomatitis
What is the criteria to be viable for surgical management with methotrexate in ectopic?
- anyone who does not meet criteria for expectant and medical
- most ectopics are dealt with surgically
- pain
- adnexal mass > 35mm
- visible heartbeat
- Hcg levels > 5000 IU/l
What are the two surgical options?
- laparoscopic salpingectomy (first line)
- laparoscopic salpingotomy
What does laparoscopic salpingectomy involve?
-general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with ectopic pregnancy
What does laparoscopic salpingotomy involve?
- used in women at increased of infertility due to damage to other tube
- aim to avoid removing affected fallopian tube and cut in to just remove the ectopic then close the cut
What is risk of salpingotomy?
- increased risk of failure to remove ectopic compared to salpingectomy
- 1 in 5 women require futher treatment with methotrexate and salpingectomy after a salpingotomy
What is given to rhesus negative women having surgical management of ectopic?
-anti-rhesus D prophylaxis
