ectopic pregnancy

Question 1

differentials for PV bleeding and pain

Answer 1

ectopic pregnancy
miscarriage
molar pregnancy/hydatiform mole/gestational trophoblastic disease
subchorionic haemorrhage
cyst accident
ovarian torsion

Question 2

differentials for adnexal mass

Answer 2

ectopic pregnancy
asymptomatic enometriosis or endometrioma
tubo-ovarian abscess
luteoma
ovarian cyst
leiomyoma in the broad ligament
benign neoplasm
malignant neoplasm

Question 3

define ectopic pregnancy

Answer 3

implantation of developing blstocyst outside the uterine cavity, most commonly in the fallopin tube

Question 4

risk factors for ectoptic pregnancy

Answer 4

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

Question 5

most symptoms of ectopic pregnancy occur at

Answer 5

week 4-8 after LMP

Question 6

clinical finings

Answer 6

signs: hypotension, tachycardia, pallor, shock
pelvic tenderness, adnexal mass
cervical motion tenderness

Question 7

major ectopic pregnancy complcation

Answer 7

tubal distension causing tubal rupture and intraabdominal haemorrhage + shock

Question 8

the 3 ways to manage an ectopic pregnancy

Answer 8

1. expectant
2. medical
3. surgery

Question 9

expectant management is suitable for

Answer 9

<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

Question 10

medical mangement is suitable for

Answer 10

<3.5cm mass
<5000 bHCG
haemodynamically stable
unruptured tubal or other ectopic pregnancy
normal bloods
compliant patient

Question 11

reasons that would exclude someone from the option of expectant management

Answer 11

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

Question 12

the sort of patient that would be appropriate for surgical management

Answer 12

haemodynamically unstable
confirmed impending or ongoing rupture of the ectopic pregnancy
co-existing intrauterine pregnancy
contraindication of medical treatment
patient choice

Question 13

standard surgical procedure for ectopic pregnancy

Answer 13

salpingectomy
laparoscopic is ideal in the desire for future pregnancy

Question 14

salpingostomy

Answer 14

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

Question 15

anti-D

Answer 15

given to all non sensitised women who are rhesus negative

Question 16

common places for ectopic pregnancies

Answer 16

fallopian tube
caesarean/hysterotomy scar, ovary, rudimentary horn of unicornuate uterus, cervix, abdomen

Question 17

symptoms of ectopic preganancy

Answer 17

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

Question 18

diagnosis via TVUS scan

Answer 18

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

Question 19

if the pt denies TVUS scan

Answer 19

offer transabdominal US scan and explain how findings will be limited, with the low specificity of the test making an ectopic diagnosis difficult

Question 20

three ways to diagnose ectopic

Answer 20

1. TVUS only
2. TVUS plus discriminatory zone hCG
3. TVS plus serial hCG

Question 21

discriminatory zone hCG

Answer 21

the serum hCG level above which a gestational sac should be visualised

Question 22

follow up during expectant management

Answer 22

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

Question 23

drug used for medical management for ectopic pregnancy

Answer 23

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

Question 24

follow up for medical management

Answer 24

Question 25

advise post medical management of ectopic pregnancy

Answer 25

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