Ectopic Pregnancy

Question 1

Define ectopic pregnancy

Answer 1

Pregnancy resulting from fertilised ovum implanting into a site other than the normal uterine cavity.

Question 2

What are the primary RF for ectopic pregnancy

Answer 2

• Smoker
• Previous ectopic pregnancy
• STI hx (usually chlamydia)
• numerous sexual partners
• Previous reproductive surgery (tubal sx)
• History of PID
• IUD use.
• developmental disorders leading to tubal dysfunction.

Question 3

What are the areas of implantation of ectopic pregnancies (classifications), and which are the most common?

Answer 3

Ovarian: 1-3%
TUBAL - 95%
          - mainly: ampulla. 
Cervical: <1%
Abdominal: 1-4%

Question 4

What are the key clinical features of ectopic pregnancy

Answer 4

• Abdo Pain (usually RLQ).
• Amenorrhea - typically 6-8 weeks prior to presentation
  OR bleeding (heavy seen w cervical pregnancy).
• Unruptured: usually unremarkable examination, possible adnexal mass/tenderness.
• Ruptured: haemodynamically unstable, involuntary guarding/rebound tenderness, blood in vaginal vault, acute abdo/shoulder/cervical motion tenderness.

Question 5

What are the order of investigations to diagnose ectopic pregnancy?

Answer 5

1. Beta HCG
2. TVS
   - rising levels of B-HCG (1200-1500) + absence of gestational sac on TVS = ectopic pregnancy until proven otherwise.

Extra
3. Laparoscopy - Pregnancy of unknown location (PUL)

Question 6

What are the management options for ectopic pregnancy?

Answer 6

1. Low Risk:
   - HCG <200 u/L and falling
   - Ectopic Mass: <3cm
   - Haemodynamically stable (no signs of rupture).
   –> Expectant management (wait and see: resolves in 70% of cases if well managed).
   NB - risk: can rupture at low levels.
2. Moderate Risk
   - HCG <500 u/L
   - Ectopic Mass: <4cm.
   - Haemodynamically stable
   - -> Medical management: methotrexate w weekly HCG levels taken until negative.
3. High Risk/ruptured
   - Haemodynamically unstable, pain, vomiting.
   - -> Always surgical:
   - salpingectomy (complete removal of tube, ovary is left)
   - salpingostomy (removal of the mass only)

Question 7

What is the difference between a recurrent ectopic pregnancy and a persistent ectopic pregnancy?

Answer 7

Recurrent - recurs after a previous one is completely resolved.

Persistent - incomplete resolution of an ectopic pregnancy. Ie - through expectant/medical treatment.