ECTOPIC PREGNANCY Flashcards
What is ectopic pregnalancy
Ectopic pregnancy is when implantation of the foetus occurs outside the endometrial cavity
Types of ectopic pregnancy
Tubal (isthmus, ampullary and fimbrial)
Abdominal
Ovarian
Cervical
Intramural
CS section
Interstitial or Cornual
Risk factors
Smoking
Maternal age
Infertility
Multiple sexual partners
History of STI or PID
History of ectopic pregnancy
Tubal surgery, abnormalities
Assisted reproductive technologies
Use of progestin only contraceptives
Differentials
Spontaneous abortion
PID
Appendicitis
Urinary calculi
Ruptured corpus luteum cyst or follicle
Ovarian torsion
Tubo-ovarian abscess
Symptoms of ectopic pregnancy (Classical triad)
Amenorrhea
Abdominal pain
Abnormal vaginal bleeding
Other symptoms of ectopic pregnancy
Fatigue, dizziness, syncope
GIT symptoms (rectal pressure or dyschezia)
Shoulder tip pain
Urinary symptoms
Breast tenderness
Cardiac arrest
Common Signs of ectopic pregnancy
Adnexal tenderness
Pelvic tenderness
Abdominal tenderness
Other signs of ectopic pregnancy
Cervical motion tenderness
Uterine tenderness
Pallor
Abdominal distension
Tachycardia
Adnexal mass
Shock/Collapse
Danger signs for ectopic pregnancy
Involuntary guarding
Severe tenderness
Abdominal rigidity
Evidence of haemorrhagic shock
Findings on pelvic examination in ectopic pregnancy
Enlarged, soft uterus
Cervical motion tenderness
Uterine motion tenderness
Adnexal mass and tenderness
Uterine contents in vagina due to endometrial shedding
Diagnostic tests in ectopic pregnancy
Urine pregnancy test
Serum beta-HCG
Ultrasonography
Laparoscopy
Diagnostic criteria for discriminary beta-HCG zone with ultrasound
-No intrauterine gestation sac on Transvaginal ultrasonography and beta-HCG between 1500IU/L TO 1800IU/L to a max of 2300IU/L
-No intrauterine gestation sac on abdomiopelvic ultrasonography and beta-HCG between 6000-6500IU/L
Management protocols for ectopic pregnancy
Expectant management
Medical management
Surgical management
Meaning of the discriminatory beta-hCG zone
The discriminatory zone is the β-hCG level at which the pregnancy should be visible and varies by the quality of the ultrasound machine
Normal beta-HCG levels in pregnancy
Doubles every 48 to 72 hours to a maximum of 10,000 to 20,000 mIU/mL
Use and value of the beta HCG discriminatory level in ectopic pregnancy
The hCG discriminatory level is to be used as a diagnostic aid in women at risk of ectopic pregnancy, the value should
be as high as 3,500 mIU/mL
Criteria for expectant management of ectopic pregnancy
Clinically stable and pain free
Beta-hCG level <1000mIU/L
Ectopic mass less than 35mm or 3cm
No visible foetal cardiac activity
Able to return for followup
Monitor beta-hCG levles on days 2,4 and 7 and adjust managment plan
Agents that can be used for medical management of ectopic pregnancy
Methotrexate
Potassium chloride
Hyperosmolar glucose
Prostaglanding F2a
Absolute contraindications to Methotrexate in management of ectopic pregnancy
Active GIT bleeding
Acute pulmonary oedema
Clinically significant hepatic or renal disorder
Thrombocytopenia, Leucopenia, moderate to severe anemia
Lactation
Peptic ulcer
Ruptured ectopic pregnancy
Intrauterine pregnancy
Immunodeficiency
Relative contraindications to methotrexate therapy
Beta-HCG > 5000mIU/mL or > 10,000mIU/mL
Foetal cardiac activity
Ectopic mass >4cm
Significant free fluid
Adverse effects of methotrexate
Nausea, Vomiting and Diarrhea
Hypersensitivity
Stomatitis, Dermatitis, Pneumonitis
Dizziness
Reversible alopecia
Bone marrow suppression
Different regimens for methotrexate in ectopic pregnancy compared
Single dose regimen: less adverse effects, highly effective
Two dosage regimen: moderate adverse effects, more effective than single dosage
Multiple dosage regimen: more adverse effects, not more effective than multiple dosage regimen
Two dose regimen for methotrexate
DAY 1
FBC, LFT & RFT
Determine β-hCG level
Administer single dose of methotrexate, 50 mg per m2
DAY 4
Measure β-hCG level
Administer second dose of methotrexate, 50 mg/m2
DAY 7
Measure β-hCG level
If decrease from days 4 to 7 is ≤ 15%, offer choice of further methotrexate doses or refer for surgical management;
DAY 7-14
Further methotrexate doses should be 50 mg/m2 on day 7 with measurement of β-hCG level on day 11, then another dose of 50 mg/m2 on day 11 if β-hCG level does not decrease ≤ 15% from days 7 to 11
if β-hCG level does not decrease ≤ 15% from days 11 to 14, refer for surgical management
If decrease from days 4 to 7 is > 15%, measure β-hCG levels weekly until they are undetectable
Single dosage regiemn for methotrexate
Day 1- measure serum beta-HCG, LFT, FBC and RFT levels and give 50mg/m2 of methotrexate IM
Day 4- measure serum beta-hCG, an initial increase expected, use this as baseline for further evaluation
Day 7: measure serum beta-hCG levels,
If an increase of greater than 15% of baseline, monitor beta-hCG levels till negligible
If increase is <15%, give second dose of methotrexate and measure again on day 4 from dose and day 7, if still ineffective, consider surgical management
Multiple dosage regimen for methotrexate
Alternate every other day: 1 mg/kg MTX IM and 0.1 mg/kg leucovorin (folinic acid) starting with MTX on day 1
Give up to four doses of each medication or till serum beta-hCG levels decrease by >15% then monitor weekly till levels are undetectable
LFTs, CBC, and RFTs at baseline
Beta-hCG at baseline, day 1, day 3, day 5, and day 7 until levels decrease then weekly
Success rate of MTX based on initial beta-hCG level
< 1,000 —————- 98
1,000 to 1,999 —————- 94
2,000 to 4,999 —————- 96
5,000 to 9,999 —————- 85
≥ 10,000 —————- 81
Mechanism of action of MTX in ectopic pregnancy
MTX is an anti-metabolite and a folate analog.
It competitively inhibits dihydrofolate reductase (DHFR) which reduces folate to its biologically active form.
This inhibits rapidly dividing cells including trophoblastic cell.
Difference between folinic acid and folic acid
Folinic acid is a reduced bioactive form of folic acid that bypasses the block by MTX
Readily converted to reduced folic acid derivatives and it does not require of DHFR for its conversion
Folinic acid is more effective at preventing side effects of MTX compared to folic acid
How can folic acid be given for MTX toxicity
PO 5 mg once weekly, dose to be taken on a
different day to methotrexate dose
Criteria for surgical management in ectopic pregnancy
Ruptured ectopic pregnancy
beta-hCG> 5000 or sometimes 10,000mIU/mL
Foetal heartbeat
Clinically unstable
Ectopic mass > 4cm or 35mm
Surgical management of ectopic pregnancy
Laparoscopy with salpingostomy or salpingectomy
Laparotomy if laparoscopy cannot be done
Salpingostomy vs salpingectomy
Salpingostomy
Preferred if contralaterl tube is destroyed
Preferred if plans of conception
Preferred in unruptured ectopic pregnancy
Salpingectomy
Preferred in ruptured ectopic pregnancy
Preferred if no plans of conception
Preferred if contralateral tube is healthy
Problems with salpingostomy
risk of persistent trophoblast with the need for serum b-hCG level follow-up.
risk of needing further treatment in the form of systemic methotrexate or salpingectomy
Role of Anti-D in ectopic pregnancy
Anti-D prophylaxis for all rhesus negative mothers who undergo surgery for ectopic pregnancy (250IU or 50mcg)
