Ectopic Pregnancy

Question 0

History typical of ectopic pregnancy? Referred pain to? If ruptured?

Answer 0

Abdominal pain, 4-6 weeks of amenorrhea, irregular vaginal spotting

Shoulder pain – from blood irritating the diaphragm

Syncope

Question 1

HCG produced by?

Answer 1

Synctiotrophoblasts

Question 2

Signs of ectopic pregnancy?

Answer 2

Tachycardia, hypertension, orthostasis

Adnexal tenderness, adnexal mass, hemoperitoneum

Question 3

Confirm hemoperitoneum with?

Answer 3

Culdocentesis – Aspiration of blood with spinal needle piercing the posterior vaginal fornix

Question 4

Risk factors for ectopic pregnancy?

Answer 4

1. Salpingitis (chlamydia)
2. Tubal problems - Tubal adhesive disease, tubal surgery, prior ectopic pregnancy, congenital abnormalities of the tube
3. Progesterone secreting IUD
4. Ovulation induction, infertility

Question 5

Differential diagnosis for ectopic pregnancy?

Answer 5

1. Ovarian – ruptured corpus luteum
2. Tubal – acute salpingitis, adnexal mass
3. Uterine - endometriosis, dysfunctional uterine bleeding, Leiomyoma, abortion
4. Extrauterine – acute appendicitis

Question 6

Transvaginal ultrasound can detect pregnancy is as early as? Finding if intrauterine? Extrauterine?

Answer 6

5 1/2 weeks

Crown-rump length or yolks sac

Embryo outside uterus, large amount of intra-abdominal free fluid (blood)

Question 7

Intrauterine gestational sac will be seen when hCG levels reach? If no gestation sac visible, next step?

Answer 7

1500, laparoscopy

Question 8

Progesterone level in normal versus abnormal pregnancy?

Answer 8

Over 25 versus under 5

Question 9

Indications for salpingectomy versus salpingostomy?

Answer 9

To removal – is gestation too large for medical therapy, if ruptured, if woman does not want future fertility

Versus

Unruptured, woman wants to preserve fertility

Question 10

Risk of persistent ectopic pregnancy with the conservative therapy? Way to monitor?

Answer 10

10-15%; serial hCG levels

Question 11

Principal form of medical therapy for ectopic pregnancy? Route and dosing? Max size of pregnancy? Outcome?

Answer 11

Methotrexate; one low-dose IM injection; less than 4 cm in diameter; 85-90% successful

Question 12

Typical complication of methotrexate? Observe in case of? Signs of major complication? Tx? (Percentage of patients with major complication?)

Answer 12

3-7 days following therapy, patient complains of abdominal pain (due to tubal abortion)

Rupture – hypotension, persistent pain, falling hematocrit

Surgery (10%)

Question 13

Patient with HG level below threshold presents with acute abdomen – likely diagnosis? Management?

Answer 13

Ruptured ectopic pregnancy; surgery