Ectopic pregnancy

Question 1

Where is the most common place for ectopic pregnancy?

Answer 1

the Fallopian tubes (97%)

Question 2

What are the risk factors of ectopic pregnancies?

Answer 2

• IVF
• Pelvic infection
• Adhesion from endometriosis or infection
• Previous tubal surgery
• Use of IUCD
• Use of progestogen-only contraceptive method
• previous ectopic pregnancy

Question 3

What are the most common symptoms?

Answer 3

• Abdominal pain
• Pelvic pain
• Amenorrhoea or missed period
• Vaginal bleeding (with or without clots)

Question 4

What other symptoms may a patient with ectopic pregnancy present with?

Answer 4

Dizziness, fainting or syncope.
Breast tenderness.
Shoulder tip pain.
Urinary symptoms.
Passage of tissue.
Rectal pain or pressure on defecation.
Gastrointestinal symptoms such as diarrhoea and/or vomiting

Question 5

What are the signs from examination of an ectopic pregnancy?

Answer 5

• Pelvic or abdominal tenderness.
• Adnexal tenderness.
• Rebound tenderness.
• Cervical tenderness.
• Pallor.
• Abdominal distension.
• Enlarged uterus.
• Tachycardia and/or hypotension.
• Shock or collapse.

Question 6

How is threatened miscarriage different from ectopic pregnancy?

Answer 6

Threatened miscarriage - vaginal bleeding is the predominant feature and pain may come later as the cervix dilates.
Ectopic pregnancy - pain usually comes first and if vaginal bleeding occurs it is of much less significance.

Question 7

What are the investigations?

Answer 7

• Pregnancy test
• Transvaginal USS - most accurate to detect tubal pregnancy.
• Human chorionic gonadotropin (hCG) - taken 48 hours apart - compare decline and rise.

Question 8

What medical management is used in ectopic pregnancy? What are the criteria?

Answer 8

Single-dose methotrexate
Criteria:
- no significant pain
Unruptured E.P. with mass <35mm and no heart beat
No pregnancy on USS.
Serum hCG <1500

Question 9

What should be considered when methotrexate is used?

Answer 9

LFTs - liver function
hCG levels are dropping
Contraception used for 3 to 6 mths.

Question 10

When should surgery be offered? What type of surgery?

Answer 10

Laparoscopic 
Significant pain
Adnexal mass >35mm
Fetal heartbeat visible on scan.
Serum hCG level >2500