Ectopic Pregnancy Flashcards
What is an ectopic pregnancy?
- Pregnancy that implants outside the uterine cavity
- Over 95% occur in fallopian tube
Describe the pathophysiology of an ectopic pregnancy?
What are the 3 outcomes of a tubal pregnancy
- Implantation of trophoblast in tube
- Erodes through mucosal layer of the tube and into vessels causing bleeding into endometrial cavity (causes spotting) & Peritoneum (hemoperitoneum)
- Blood caught between serosal and mucosal layers of tube causing cervical motion tenderness
- If bleeds enough, results in pressure necrosis of the tubal serosa and significant hemoperitoneum
What is the classic triad of ectopic pregnancy?
1) Missed menses
2) Vaginal bleeding (typically spotting)
3) Lower abdo pain
Previous ectopic pregnacy is one of the greatest risk factors for subsequent ectopic. What is the recurrence rate following an ectopic pregnacy?
- 30%
Do IUD’s increase risk of ectopic pregnancy?
- Overall no, due to decreased rate of pregnancy
- However, up to 40% of pregnancy in patients with IUD in place are ectopic
- Progestins slow tubal peristalsis meaning the oocyte is in the tube much longer and if becomes fertilized may progress too slowly and become stuck
How does assisted reproductive technology affect the rate of ectopic pregnancy?
- Increases risk
- High levels of progesterone used to hyperstimulate ovaries
- Progesterone slows tubal motility increasing risk of ectopic
Which area of the fallopian tube do ectopic pregnancies occur in the most?
- Ampulla (75-80%)
What is a heterotopic pregnancy?
- When there are simultaneous implantation of pregnancies in both the endometrium and an extrauterine site
- May occur in as many as 1 in 100 IVF pregnancies
What are the 3 outcomes of a tubal pregnancy
1) tubal rupture and hemorrhage
2) Resorption of pregnancy (due to interrupted blood supply)
3) Tubal abortion into peritoneal cavity (rarely results in abdominal pregnancy)
How would someone present with an acutely ruptured ectopic pregnacy?
Symptoms indicative of massive hemorrhage
- Dizziness
- loss of consciousness
- Sudden onset severe pain
- Shoulder pain may be present due to irritation of phrenic nerve in peritoneum
Physical:
- Tachy
- Diaphoresis
- Hypotensive
- Peritonitis
How would you manage an acutely ruptured ectopic?
- Surgical emergency
- Large bore IV’s and fluid resuscitation
- Blood transfusion
- Laparotomy typically
What is a probable ectopic pregnancy?
- Postive pregnancy test, presenting with notable pelvic pain and spotting after other disease processes relating to early pregnancy are ruled out
What is the double ring sign? The ring of fire sign?
Double ring: Echogenic ring surrounding ectopic pregnancy
Ring of fire: Doppler flow showing ring of vascularity around ectopic
What is the expected doubling time of B hCG in a normal pregnancy?
- 48 hours in the first few weeks of a pregnancy
At what hCG level should you be expected to see an IUP by transvaginal ultrasound?
1500 - 2000 IU
At what hCG level should you be expected to see an IUP by transabdominal ultrasound?
- 6500 IU
What effect does having a salpingectomy have on a womans future fertility
- There does not seem to be any difference
- 10-20% increase risk of residual trophoblastic tissue is associated with saplinostomy (when entire tube isnt removed)
What is the medical management of an ectopic pregnancy?
- Methotrexate
- Patient returns on days 4 and 7 for repeat hCG levels
- hCG levels must fall at least 15% between the return days (if not then repeat dose or surgery)
- Following this followed every 7 days looking for 15% decrease per week
- Follow down until hCG is undetectable
What criteria must someone meet to be able to try medical management of ectopic?
- Stable
- Ability to follow-up
- Ectopic mass size under 3-4 cm
- No cardiac motion seen
- hCG levels less than or equal to 5000
- Normal renal and hepatic function
What additional treatment should you provide to all Rh-negative, unsensitized women with ectopic pregnancy?
RhoGAM
How long after an ectopic pregnancy should future pregnancy be avoided?
- 3 months
- Allow for tubes to normalize and for methotrexate to clear system
- Should use highly effective contraception during interm
