ectopic pregnancy

Question 1

sites of ectopic pregnancy

Answer 1

*interstitial
*tubal(isthmus)
*tubal(ampullar) 80%
*infundibular (ostial)
*ovarian
*peritoneal
*cervical
*abdominal

Question 2

Risk Factors of ectopic prgnancy

Answer 2

due to damage in the fallopian tubes
1. Pelvic inflammatory disease (adhesion)(salpingitis)
2. Tubal surgery in the past
3. Endometriosis , leiomyoma
4. Smoking and exposure to DES in utero
5. Women with infertility due to tubal factors undergoing IVF
6. Previous ectopic pregnancy

Question 3

Clinical Presentation of ectopic pregnancy

Answer 3

*pelvic and abdominal pain (mainly on the pregnancy side)
*Vaginal bleeding, amenorrhea
*syncope(specially if ruptured)
*On physical exam adnexal mass (not always)
can occasionally be palpated.
*could be asymptomatic

Question 4

investigation and diagnosis of ectopic pregnancy

Answer 4

*Gold standard : Transvaginal US
*Check BHCG titer : if more than 1500 +there is no pregnancy inside the uterus = ectopic pregnancy.
*determine the location of the pregnancy by abdominal ultrasound

Question 5

important signs

Answer 5

*diffuse or localized abdominal tenderness
*unilateral adnexal mass
*uterine changes
*hemodynamic instability

Question 6

treatment

Answer 6

*expectant: in asymptomatic women /low hcg/evidence of spontaneous resolution (decrease in hcg levels)

*medical: methotrexate (MTX is given IM)
(hemodynamically stable women) (normal BP)

*surgical:mainly for women with contraindication to MTX or evidence of tubal rupture

Question 7

contraindication to methotrexate(مهم للحفظ)
(medexam)

Answer 7

*hemodynamically instable (<90/60)
*cardiac motion
*gestational sac >3.5 cm
*hcg>5000
*blood dyscrasias
*active GI/respiratory disease
*hepatic or renal disease

Question 8

next step after treatment

Answer 8

*follow up of hcg levels until reach zero
**if hcg do not decrease -> additional mtx or surgery (Laparoscopy is superior to laparotomy)

***Its recommended for women treated with methotrexate to wait at least for 3 months, before trying to concieve again

Question 9

surgical management:

Answer 9

*Salpingectomy : remove the whole or part of the tube
*Salpingotomy: remove the pregnancy from the tube and keep it in place

**In the presence of healthy contralateral tube , salpingectomy should be performed in the preference of salpingotomy

Question 10

when the tubal (ampullar) ectopic pregnancy most likely to rupture

Answer 10

8-12 weeks

Question 11

when the tubal(isthmus) ectopic pregnancy most likely to rupture

Answer 11

after 6-8 weeks

Question 12

when the tubal(interstetial ) ectopic pregnancy most likely to rupture

Answer 12

the longest ,it takes till 12-16 weeks

Question 13

heterotopic pregnancy

Answer 13

**more than one pregnancy in different locations
**mainly in IVF treated women

Question 14

heterotopic pregnancy management

Answer 14

**no drugs are given (to maintain the healthy one )
**laparoscopy the best way
**KCL could be given directly into the fetal sac transabdominally

Question 15

absolute contraindications to methotrexate (حفظ ضروري)

Answer 15

*breast feeding
*immunodeficiency
*alcoholism /alcoholic liver disease /chronic liver disease
*blood abnormalities (leukopenia,thrombocytopenia ,sever anemia)
*active pulmonary disease (with ongoing medication)
*peptic ulcer disease
hepatic /renal/hematological dysfunction

Question 16

relative contraindications to methotrexate (حفظ ضروري)

Answer 16

*gestational sac > 3.5
*embryonic cardiac motion

Question 17

follow up after methotrexate

Answer 17

*check hcg on day 4 & 7
* if didn’t decreases ,increase the dose or laparoscopy
* recommended to wait 3 months before next pregnancy

**methotrexate given IM **