Ectopic pregnancy Flashcards
Ectopic pregnancy refers to
the implantation of blastocyst in tissue other than the endometrium of uterine cavity
How common is it?
What are the risk factors?
In general population 1/200
High risk can be as high as 1/30
Risk factors: STIs and PID previous ectopic previous tubal surgery hormonal - progestogens contraceptive failures increasing age smoking IVF
What are the most common ectopic sites?
1) 97% Fallopian tube (70% ampulla, 12% fimbrial end, 11% isthmus)
2) Ovary, cervix, broad lig, CS scar, peritoneal cavity
What are the main symptoms of ectopic pregnancy?
pelvic pain (initially unilateral but may become generalised) delayed period or abnormal bleeding Shock in case of rupture
What would I examine for if I suspected ectopic pregnancy?
1) Signs of shock - tachycardia, hypotension and pallor
2) Abdo - guarding and peritonism
3) VE - bleeding, closed cervix, small uterus for gestational age, adnexal mass, tenderness
What are the 2 most important diagnostic tools? How do we interpret them?
TV USS and serial B-hCG
Combined - The absence of intrauterine gestation sac on TVS when B-hCG is 1500 IU/mL –> ectopic pregnancy
(the ectopic pregancy itself may not be visualised)
Serial B hCG 48 hours - A suboptimal rise of <60% is suspicious for ectopic
What is the emergency management of ectopic pregnancy in a haemodynamically unstable patient (i.e. rupture)?
1) Recognise emergency - call for help - gynaecology reg, anaesthetists, OT staff and ICU and nursing and commence resuscitation of shocked patient
2) IV access - 2 wide bore cannulae , send blood for FBC, Gp and cross match 2 - 4 units, B hCG
3) Give IV N/S 1L stat
4) To OT for laparoscopic salpinostomy - explain to patient and get verbal consent
5) Post-op - anti-D for Rh-neg women and follow up as below
What is the medical management option? Who might this be considered for? What follow-up is required and what advice regarding conception?
In selected cases - asymptomatic, stable patient with B hCG < 3500 - could give methotrexate (antimetabolite that interferes with DNA synthesis to prevent growth of rapidly dividing cells)
Serum B hCG on days 4 and 7 - if failure to fall between these days by 15% give 2nd dose.
Weekly B hCG until <5 IU/ml
Advise to defer conception for 4 months
What follow up is required for a patient after surgical/medical tx of ectopic pregnancy?
1) All Rh-neg women should be given 250 IU anti-D
2) Weekly B hCG until <5 IU/mL to exclude persistent trophoblast
3) Counselling - fertility outcomes and future risk - if no previous fertility problems, IUP rate is 85%, with 7.5% risk recurrent ectopic and 7.5% infertility
Advise woman to have early TV USS at 5-6 weeks in future pregancies to confirm IUP.
4) Grievance counselling should be available as needed.
