Ectopic Pregnancy

Question 1

What is an ectopic pregnancy? How often does it occur in pregnancy?

Answer 1

It is implantation of the conceptus in a place outside the uterine cavity, usually in the fallopian tubes. It can also be placed in the ovary, abdomincal cavity or the cervix. Occurs in 1% of pregnancies.

Question 2

What is the triad of symptoms associated with ectopic pregnancy?

Answer 2

1. Amenorrhoea
2. Lower Abdominal Pain
3. Vaginal Bleeding

Question 3

There are 5 main predisposing factors for an ectopic pregnancy. What are they?

Answer 3

1. Previous ectopic pregnancies
2. Progesterone only or emergency hormonal contraception
3. Intrauterine Device (IUD)
4. IVF pregnancy
5. Tubal Damage or adhesions

Question 4

Explain how tubal damage/adhesions can lead to the development of an ectopic pregnancy?

Answer 4

Abnormalities of the fallopian tube (narrowing or kinking) can prevent the ovum from progressing to the uterus from the ampulla. Also damage to the cilia of the tubal epithelium can impede transport of the fertilised ovum.

Question 5

In the tubal pregnancy, what are the 3 possible outcomes that can result? Explain simply what each is.

Answer 5

1. Tubal Abortion – ectopic pregnancy moves out through the fimbriae
2. Tubal Rupture – pretty self explanatory. If tubal abortion doesn’t occur, this is inevitable.
3. Missed Tubal Abortion – embryo can die and be absorbed.

Question 6

Explain what Tubal Abortion is.

Answer 6

The conceptus goes out of the fimbrial end of the tube. There will be a colicky pain but then progresses to a constant pain as a result of the blood in the peritoneal cavity. This usually settles spontaneously but if there is persistent bleeding and pain then may need surgical opinion.

Question 7

Explain what tubal rupture is.

Answer 7

If tubal pregnancy continues and there is no tubal abortion then tubal rupture is inevitable. In this case, compared to tubal abortion, there is severe peritoneal bleeding and acute abdominal pain. Pain can refer to the shoulder tip because of blood in the abdomen and can also be pain on defecation because of blood in the pouch of Douglas between rectum and the upper vagina. Can present as haemodynamic collapse.

Question 8

Where are the three places where tubal rupture can occur?

Answer 8

1. Tubal lumen
2. Broad Ligament
3. Peritoneal Cavity

Question 9

Explain what Missed Tubal Abortion is.

Answer 9

If the embryo dies then it can be absorbed. This usually happens in early pregnancy and has brown/red vaginal loss with or without abdominal pain.

Question 10

List the 5 other sites of ectopic pregnancy.

Answer 10

• Cornual/Interstitial Pregnancy
• Cervical Pregnancy
• Uterine Scar Pregnancy
• Heterotopic Pregnancy
• Abdominal Pregnancy

Question 11

Discuss Cornual/Interstitial Pregnancy

Answer 11

Ectopic pregnancy in the proximal tube but in the musculature of the uterus. Since it is in the musculature, women with this sort of ectopic pregnancy actually present later because of the thicker coat. Furthermore, the rupture can be more sudden and there can be catastrophic blood loss.

Question 12

Discuss Cervical Pregnancy

Answer 12

This is rare but you must consider this when there is heavy bleeding on vaginal examination. On examination, there will be a small, firm uterus with an expanded cervix. Important to distinguish between this and the passage of products in a miscarriage. An U/S is required in this setting.

Question 13

Discuss Heterotopic Pregnancy

Answer 13

Combination of an intrauterine and extrauterine pregnancy. This is common in IVF pregnancies.

Question 14

Discuss Abdominal pregnancy

Answer 14

This is rare. There are two types. Primary abdominal pregnancy occurs when there is implantation of fertilised ovum in the peritoneal cavity. Secondary abdominal pregnancy occurs when there is implantation following tubal abortion.

Question 15

How do you make the diagnosis of an ectopic pregnancy?

Answer 15

Beta-hCG + Ultrasound

Question 16

What do you need to consider in the immediate management of an ectopic pregnancy?

Answer 16

There could potentially be a ruptured ectopic pregnancy which could present with haemodynamic collapse and therefore a medical emergency for maternal collapse.

Question 17

What 5 steps are important in the management of haemodynamic collapse following a ruptured ectopic pregnancy?

Answer 17

1. Secure IV access
2. FBE
3. Cross match
4. Coag screen
5. If required, resuscitation with O- blood

Question 18

What is the management of subacute or asymptomatic situations in the context of a suspected ectopic pregnancy?

Answer 18

IV access, blood tests with or without IV fluid based on the hydration status of the patient.

Question 19

Discuss the medical management of a confirmed ectopic pregnancy.

Answer 19

Methotrexate is the primary treatment. It is folate antagonist and it inhibits DNA synthesis in rapidly dividing cells. There is still a risk of ectopic rupture. Patient needs to present weekly for beta-hCG assessment as it may take several weeks for the beta-hCG to return to normal and the resolution of the ectopic pregnancy. The beta-hCG will decrease by >15% in days 4-7 with successful treatment but multiple doses may be necessary.

Question 20

Discuss surgical management of ectopic pregnancy

Answer 20

This surgical management only takes place when medical management fails or is contraindicated. Most commonly use laproscopic technique except those in haemodynamic collapse. Also laproscopic salpingectomy (removal of the fallopian tube) is standard. Can do a salpingostomy (incision of the tube and removal of products of conception) in patients with contralateral tubal disease.