ectopic pregnancy Flashcards
differentials for PV bleeding and pain
ectopic pregnancy
miscarriage
molar pregnancy/hydatiform mole/gestational trophoblastic disease
subchorionic haemorrhage
cyst accident
ovarian torsion
differentials for adnexal mass
ectopic pregnancy
asymptomatic enometriosis or endometrioma
tubo-ovarian abscess
luteoma
ovarian cyst
leiomyoma in the broad ligament
benign neoplasm
malignant neoplasm
define ectopic pregnancy
implantation of developing blstocyst outside the uterine cavity, most commonly in the fallopin tube
risk factors for ectoptic pregnancy
previous ectopic pregnancy
previous tubal surgery
failed tubal ligation
documented tubal damage or pathology
failed IUCD
hx innfertilty
previous pelvic/genital infection
cigarette smoking
multiple sexual partners
assisted reproductive technology
previous pelvic/abdominal surgery
early age at first sexual intercourse
vaginal douching
most symptoms of ectopic pregnancy occur at
week 4-8 after LMP
clinical finings
signs: hypotension, tachycardia, pallor, shock
pelvic tenderness, adnexal mass
cervical motion tenderness
major ectopic pregnancy complcation
tubal distension causing tubal rupture and intraabdominal haemorrhage + shock
the 3 ways to manage an ectopic pregnancy
- expectant
- medical
- surgery
expectant management is suitable for
<3cm size of mass
<1000 bHCG and declining progressively
minimal pelvic free fluid and no yolk sac seen on US
absent or minimal clinical symptoms and no sign of rupture or intra peritoneal bleed
medical mangement is suitable for
<3.5cm mass
<5000 bHCG
haemodynamically stable
unruptured tubal or other ectopic pregnancy
normal bloods
compliant patient
reasons that would exclude someone from the option of expectant management
haemodynamically unstable
signs of impending or ongoing ectopic mass rupture
an HCG above 1000 or one that is not declining
living more than 30 minutes from hospital
unwilling or unable to comply with follow up
the sort of patient that would be appropriate for surgical management
haemodynamically unstable
confirmed impending or ongoing rupture of the ectopic pregnancy
co-existing intrauterine pregnancy
contraindication of medical treatment
patient choice
standard surgical procedure for ectopic pregnancy
salpingectomy
laparoscopic is ideal in the desire for future pregnancy
salpingostomy
incision into the fallopian tube over the site of the ectopic pregnancy nd removal of the ectopic pregnancy to spare and retain patency of the fallopian tube ie. preserving it
shown in evidence not to improve fertility outcomes
anti-D
given to all non sensitised women who are rhesus negative
common places for ectopic pregnancies
fallopian tube
caesarean/hysterotomy scar, ovary, rudimentary horn of unicornuate uterus, cervix, abdomen
symptoms of ectopic preganancy
normal discomforts of pregnancy (eg. breast tenderness, frequent urination, nausea)
plus typical triad:
- bleeding
- abdominal pain
- amenorrhea
less common symptoms: dizziness/fainting, shoulder tip pain, passage of tissue, GI symptoms like diarrhoea or pain on defacation
diagnosis via TVUS scan
TVUS is the most useful primary investigation
combination of
1. postive pregnancy test
2. empty uterine cavity
3. complex adnexal mass +/- extrauterine gestational sac is diagnostic
other US features may include: bagel sign, pseudo sac, pelvic free fluid
if the pt denies TVUS scan
offer transabdominal US scan and explain how findings will be limited, with the low specificity of the test making an ectopic diagnosis difficult
three ways to diagnose ectopic
- TVUS only
- TVUS plus discriminatory zone hCG
- TVS plus serial hCG
discriminatory zone hCG
the serum hCG level above which a gestational sac should be visualised
follow up during expectant management
hCG measurements day 3 and 7
TVUS day 7
if there is hCG drop by >50% and reduction in size of the adnexal mass, continue with weekly hCG until <5.
otherwise, continue to medical or surgical management
drug used for medical management for ectopic pregnancy
IM methotrexate to the buttock or thigh (may also be given as a direct local injection into the ectopic sac under TVUS guidance or laparoscopically)
outpatient treatment
follow up for medical management
advise post medical management of ectopic pregnancy
avoid vaginal intercourse untl hCG is undetectable
avoid pregnancy for three months due to theoretical risk of methotrexate teratogenicity
avoid sun exposure due to risk of methotrexate dermatitis
avoid foods and vitamins containing folic acid
avoid NSAIDs
