Ectopic pregnancy

Question 1

What is an ectopic pregnancy

Answer 1

is a pregnancy that occurs outside of the uterus.

Question 2

What are common sites for implantation (3)

Answer 2

1. Tubal (95%)
   -ampullary (70%)
   -isthmus (12%)
   -fimbrial end (11%)
   -interstitial (2-3%)
2. ovarian 3%
3. <1% cervix, cesarean scar, abdominal, intraligamentous

Question 3

What are the risk factors (5)

Answer 3

1. Prior ectopic pregnancy
2. Prior Bilateral Tubal Ligation
3. History of PID
4. Endometriosis (a disorder in which tissue that normally lines the uterus grows outside the uterus)
5. Current use of IUCD (just associated factor)

Question 4

what is the classical triad you will get in the history

Answer 4

• abdominal pain
• amenorrhea
• vaginal bleeding

Question 5

What things can you find on examination (5)

Answer 5

+/- tenderness (guarding, rigidity-hemoperitoneum)
+/- adnexal mass
+/- shock if ruptured
- signs of anemia (conjunctiva, palmor pallor, CRT, temp of extremities)
- cervical motion tenderness and bogginess in fornix favours ruptured ectopic pregnancy

Question 6

What investigations do you do (4)

Answer 6

• Vital signs
• urine pregnancy test
• transvaginal ultrasound
• blood samples for X-match

Question 7

how do you manage (6)

Answer 7

• Obtain IV access with 2 large bore cannulae
• Take blood samples for FBC, grouping and X-match
• If in shock then resuscitate with IV fluids RL/NS and transfuse blood
• If not in shock and
  If ruptured then perform emergency laparotomy with possible blood transfusion
  If not ruptured then consider urgent laparoscopy or laparotomy
• Send tissue to pathologist for confirmation and consider D&C if appropriate
• If patient stable, medical management can be considered at the central hospital under consultant supervision

Question 8

what drug can be used in the medical management

Answer 8

methotrexate IM

Question 9

what findings can you find on a transvaginal USS (2)

Answer 9

• is the presence of an empty uterine cavity (bagel/blob sign)
• a definite sign is the presence of a gestational sac with cardiac activity in the adnexa (tubal ring of fire sign)

Question 10

what is the surgery of choice in a ruptured ectopic pregnancy

Answer 10

salpingectomy

Question 11

in a hemodynamically stable patient with a ruptured ectopic pregnancy what do you do

Answer 11

Laparoscopic salpingectomy

Question 12

in a hemodynamically unstable patient with a ruptured ectopic pregnancy what do you do

Answer 12

laparotomic salpingectomy

Question 13

what are the pre-requisites for medical management (4)

Answer 13

• The woman should be stable, motivated and compliant to follow ups
• Beta- hCG < 3000 IU/L
• Absent cardiac activity
• Size of gestational sac < 4cm

Question 14

How do the follow ups with the medical management work

Answer 14

After a Single dose of Methotrexate is given intramuscularly, and serum levels of beta- HCG are checked on day 4 and day 7.
A further dose may be given if HCG levels have failed to fall by more than 15% between day 4 and day 7.

Question 15

what are woman advised to do during medical management (3)

Answer 15

• to avoid sexual intercourse during treatment with methotrexate
• to maintain ample fluid intake
• to use reliable contraception for three months after methotrexate has been given, because of risk of teratogenicity

Question 16

what are the prerequisites for surgical method in an unruptured ectopic pregnancy (3)

Answer 16

• Failed medical management
• Any contraindication to use of methotrexate
• Completed family

Question 17

Why would you do a salpingostomy (3)

Answer 17

• if the woman has history of infertility
• has damaged contralateral tube
• desires to have children.

Question 18

what surgery can be performed for an unruptured ectopic pregnancy (2)

Answer 18

• salpingectomy
• salpingostomy

Question 19

what is a pregnancy of unknown location

Answer 19

One where there are no ultrasound signs of (either intra- or extrauterine) pregnancy or retained products of conception with a positive pregnancy test

Question 20

what are 3 possibilities of a pregnancy of unknown location

Answer 20

• A very small or an early ectopic pregnancy which is difficult to see on an ultrasound scan
• A very early healthy intrauterine pregnancy and that the patient is not at that gestation age because she is not sure of her LNMP
• Failing or dying intrauterine pregnancy

Question 21

what approach do you use to PUL (3)

Answer 21

1. Initial step is measuring serum levels of Beta- hCG
2. If the serum levels of B- hCG <1500 IU/L (Discriminatory zone), you repeat the measurements after 48 hours.
   - If there is doubling of the serum levels of B-hCG, the pregnancy is most likely healthy intrauterine pregnancy and you offer assurance to the woman
   - If there is drastic fall in levels of serum B- hCG, the pregnancy is most likely a failing/dying intrauterine pregnancy
   - If there no change in levels of serum B-hCG and there is consequent plateauing of levels of serum B-hCG on serial measurements of the B-hCG, the pregnancy is most likely an ectopic and you need to offer medical management
3. If the initial serum levels of B-hCG >1500 IU/L, you can do Dilatation and Curettage
   - If Chorionic villi are seen after D & C, it is an intrauterine pregnancy
   - If chorionic villi aren’t seen after D & C, it is an ectopic pregnancy and you need to proceed with medical management.

Question 22

what are common symptoms of ectopic pregnancy (4)

Answer 22

Abdominal pain
Vaginal bleeding
Shoulder tip pain (referred pain)
Syncope or dizziness