Ectopic Pregnancy

Question 1

Incidence of Ectopic pregnancy

Answer 1

1% of all pregnancies

Question 2

Rate of maternal mortality due to ectopic pregnancy

Answer 2

0.2/1000

Question 3

Common sites for ectopic pregnancy

Answer 3

Tubal 98%
Others( abdomen, ovaries, cx, cs scar)

Question 4

Common sites for ectopic pregnancy

Answer 4

Tubal 98%
Others( abdomen, ovaries, cx, cs scar)

Question 5

What is heterotopic pregnancy

Answer 5

Both IUP and extrauterine pregnancy

Question 6

Incidence of heterotopic pregnancy

Answer 6

1/4000 natural pregnancy
1/100 pregnancy after ART

Question 7

Ectopic pregnancy triad

Answer 7

Amenorrhea
Lower abdominal or pelvic pain 5-14w (often unilateral)
Vaginal bleeding 5-14w (intermittent, bright or dark red)

Question 8

Uncommon symptoms of Ectopic Pregnancy

Answer 8

fainting or dizziness
breast tenderness
gastrointestinal symptoms (vomiting or diarrhoea)
shoulder-tip pain (referred pain due to peritoneal irritation)
urinary symptoms
passage of tissue
rectal pressure or pain on defecation.

Question 9

Could ectopic pregnancy be asymptomatic

Answer 9

found incidentally on an early pregnancy scan.

Question 10

Abdominal examination of ectopic pregnancy

Answer 10

tenderness, rebound tenderness, guarding, rigidity, or distension.

Question 11

Vaginal examination of ectopic pregnancy

Answer 11

cervical and/or adnexal tenderness.

Question 12

General examination of ectopic pregnancy

Answer 12

cardiovascular shock in cases of ruptured ectopic.

Question 13

Common signs of ectopic pregnancy

Answer 13

pelvic, adnexal, and abdominal tenderness

Question 14

Less common signs of ectopic preganncy

Answer 14

cervical motion tenderness, rebound tenderness or peritoneal signs
pallor
abdominal distention
enlarged uterus
tachycardia (> 100 beats per minute) or hypotension (< 100/60 mmHg)
shock or collapse
orthostatic hypotension.

Question 15

Pelvic examination when suspecting ruptured ectopic pregnancy

Answer 15

Not done.

usually difficult and information gained is limited because of generalized haemoperitoneum and pain.
It could cause total rupture of the ectopic pregnancy and it may delay management.

Question 16

Risk factors for ectopic pregnancy:

Answer 16

• Prior pelvic or abdominal surgery.
• History of an STI, previous elective termination of pregnancy, history of infertility, history of PID, previous ectopic pregnancy, or history of IUCD.
• Prior tubal surgery or endometriosis.
• About a third of women have no known risk factors.

Question 17

Complications of ectopic pregnancy

Answer 17

• Tubal rupture (depends on the site of implantation, usually after 6 weeks)
• intra-abdominal bleeding, shock.
  • Death is rare (leading cause of pregnancy-related death in the first trimester.)
  • Tubal infertility.
  • Psychological– grief, anxiety, or depression. Distress is commonly at its worst 4–6 weeks after pregnancy loss and may last 6–12 months.

Question 18

Prognosis of ectopic pregnancy if untreated

Answer 18

• Spontaneous tubal miscarriage – occurs in about 50% of ectopic pregnancies and the woman may have no symptoms. Some spontaneous tubal abortions may bleed, but the bleeding is self-limiting.
• Ruptured ectopic – intra-abdominal bleeding, shock, death.
• Chronic ectopic pregnancy.

Question 19

DD of ectopic pregnancy (pregnancy related)

*pain or bleeding in early pregnancy

Answer 19

• Miscarriage.
• Molar pregnancy.
• Early intrauterine pregnancy.
• Ruptured corpus luteal cyst.
• Degeneration of a fibroid.

Question 20

DD OF ectopic pregnancy (non pregnancy related(

Answer 20

• Cervicitis, cervical ectropion, or polyps.
• Vaginitis.
• Cancer of the cervix, vagina, or vulva.
• UTI, urethral bleeding, renal colic.
• Irritable bowel syndrome, haemorrhoids.
• Appendicitis.
• PID.
• Torsion/degeneration of a fibroid.
• Ovarian cyst (torsion, rupture, or bleeding).
• Musculoskeletal pain.
• Adhesions.

Question 21

First thing to do in assessing suspected Ectopic Pregnancy

Answer 21

Urine pregnancy test even when symptoms are nonspecific.

• Beware of atypical symptoms.
• Exclude the possibility of ectopic pregnancy, even in absence of risk factors, because about a third of women will have no known risk factors.

Question 22

In assessing EP, after positive pregnancy test:

If there is Pain and abdominal tenderness or pelvic tenderness, or cervical motion tenderness.

Answer 22

Urgent referral to EPAU/A&E

Question 23

In assessing EP, after positive pregnancy test:

If there is no Pain and abdominal tenderness or pelvic tenderness, or cervical motion tenderness.

Answer 23

If there is:
• Pain.
• Pregnancy of ≥ 6 weeks.
• Pregnancy of uncertain gestation.
⬇️
Refer to EPAU/A&E

If bleeding but not in pain and pregnancy <6 weeks:
Expectant management and repeat test after 7-10 days, return if the case worsen then refer to EPAU/A&E

Question 24

Women EP who are haemodynamically unstable, or in whom there is significant concern about the degree of pain or bleeding.

Answer 24

Urgent referral to A&E

Question 25

EPAU OR A&E

Answer 25

Early pregnancy assessment unit

Accident and emergency

Question 26

Does a negative pregnancy test exclude EP

Answer 26

almost always positive.
A negative pregnancy test in a woman with clinical features of ectopic pregnancy does not absolutely exclude an ectopic pregnancy; but does make the diagnosis highly unlikely.
In such cases, due to the rare possibility of a false-negative pregnancy test result, repeat urine pregnancy test or perform serum β-hCG.

Question 27

In what cases do we have positive serum bhcg

Answer 27

• pregnancy
• posterior cranial fossa germ cell tumor
• placental trophoblastic tumors.

Question 28

Does serum hcg is a confirmatory test for EP

Answer 28

hCG levels are a measurement of trophoblastic proliferation only and should not be used for a confirmatory diagnosis.
Final confirmation can be provided only by either an USS or a negative pregnancy test.

Question 29

Investigation for EP

Answer 29

• urine pregnancy test (if negative)
• serum Bhcg
• TVS
• color doppler (not shown to increase detection rates of EP)

Question 30

Discriminatory zone – a serum hCG level (at which it is assumed that all viable IUPs will be visualized by TVS)

Answer 30

1000–2400 IU/L

Question 31

Do we use serum progesterone measurements as an adjunct to diagnose either viable IUP or ectopic pregnancy

Answer 31

No