Ectopic pregnancy

Question 1

What aspects of the history are needed for someone with suspected ectopic pregnancy?

Answer 1

History of presenting complaint
* Confirmation of pregnancy –> urine pregnancy test, LMP
* Abdominal pain –> SOCRATES
* Shoulder tip pain
* PV bleeding –> post-coital bleeding, intermittent bleeding, post-menopausal bleeding
* Passage of clots or tissue
* Bleeding from other areas
* Dizziness / syncope

Associated symptoms
* Abnormal PV discharge
* Dyspareunia
* Urinary symptoms
* N+V or diarrhoea
* Fatigue
* Fevers / rigors

Ideas, concerns, and expectations

Past gynecological history
* Menstruation history –> duration, frequency, volume, dysmenorrhea, first day of LMP, menarche
* Previous gynecological problems or surgery
* Cervical screening history
* Last sexual intercourse
* Contraception –> current and previous
* Previous STIs or PID

Obstetric history
* Previous pregnancies and deliveries
* Previous ectopic pregnancies

Past medical history

Previous surgical history –> abdominal, other

Regular medications

Allergies

Family history
* Malignancy
* Bleeding disorders
* Blood clots

Social history
* Living circumstances
* Smoking
* Alcohol
* Recreational drugs
* Diet, exercise and weight
* Occupation
* IPV

Question 2

What examination is needed for a suspected ectopic pregnancy?

Answer 2

• Maternal vitals –> haemodynamic instability
• Abdomen exam –> tenderness (rebound, percussion), guarding, peritonism, masses, scars, skin changes, bowel sounds, PR exam
• PV exam –> anatomy of the lower genital tract, cervical motion tenderness, adnexal masses, or tenderness

Question 3

What investigations are needed for someone with suspected ectopic pregnancy?

Answer 3

• Urine pregnancy test
• Urine dipstick
• Bloods –> serum beta-hCG, FBC, UCEs, LFTs, CRP, coagulation studies, G&H, BCs
• TV USS –> IUP, free fluid, adnexal masses
• CXR –> look for air under the diaphragm if concern for perforation

Question 4

What are the differential diagnoses for ectopic pregnancy?

Answer 4

• Threatened miscarriage
• Acute appendicitis
• Septic miscarriage

Question 5

What are the common sites of implantation for an ectopic pregnancy?

Answer 5

• Tubal = 93%
• Interstitial = 1.1-6.3%
• Cervical = 0.15%
• Ovarian = 0.5%

Question 6

What are the risk factors for an ectopic pregnancy?

Answer 6

• Previous ectopic pregnancy
• ART or IVF
• History of PID
• Endometriosis
• Sterilisation or tubal ligation
• IUD

Question 7

What is the management of a haemodynamically unstable ectopic pregnancy?

Answer 7

• Transfer to the hospital
• Call for help

INITIAL
* Patient appearance - pale and unwell

AIRWAY
* Check airway patency
* Signs of life - breathing, chest rise

BREATHING
* RR, O2 sats
* Auscultate lungs, chest expansion, tracheal deviation, percussion

CIRCULATION
* HR, BP
* CRT, HS
* 2x large bore IVL in ACF
* Bloods –> FBC, UCEs, CRP, VBG, coagulation screen, beta-hCG, G&H, X-match
* 1000mL IV 0.9% saline for fluid resuscitation
* Consider activation of the MTP –> give O negative bloods once available and request X-match of 4u RBCs
* TXA 1g IV stat

DISABILITY
* AVPU, pupils, BGL

EXPOSURE
* Temperature
* Abdomen –> peritonism, tenderness, bowel sounds
* Speculum –> active bleeding
* Bimanual examination –> cervical motion tenderness, adnexal masses or tenderness

ONGOING MANAGEMENT
* Urgent senior review
* Keep NBM and inform OT + anaesthetists
* Bedside USS
* Urinalysis –> dipstick and MSU
* PV swabs including STI screening
* Analgesia + anti-emetics
* Broad spectrum IV Abx
* Ongoing monitoring of vital signs
* Fluid resuscitation +/- blood transfusion as required
* Anti-D prophylaxis (250IU IM) –> given for all ectopic pregnancies as per RANZCOG

Question 8

What are the management options for a patient with ectopic pregnancy?

Answer 8

CONSERVATIVE MANAGEMENT
Wait and watch –> monitoring beta-hCG and serial USS scans until spontaneously resolves
* Asymptomatic
* No free fluid
* Adnexal mass <35mm with no FHR present
* Beta-hCG <1000 (variable between institutions)
* Hemodynamically stable
* Sensible patient who will come for follow up

MEDICAL MANAGEMENT
IM methotrexate –> used to stop pregnancy growth and allow for resolution
* Minimal pain
* Unruptured ectopic pregnancy
* Beta-hCG < 5000
* Adnexal mass < 35mm and no fetal HR
* No free fluid
* Hemodynamically stable
* Follow up possible for patient

SURGICAL MANAGEMENT
Salpingectomy vs salpingostomy –> salpingostomy is only done if concerns regarding patency of the other tube. 20% of those with salpingostomy will need further treatment (methotrexate or salpingectomy)
* Patient preference
* Unable to return for follow up
* Ruptured ectopic pregnancy
* Significant pain
* Adnexal mass >35mm
* FHR present
* Serum beta-hCG >5000
* Haemodynamic instability