Ectopic Pregnancy

Question 1

Epidemiology

Answer 1

1 in 60-100. 95% in fallopian tube

Question 2

Risk factors

Answer 2

1. cilial dmg from infections
2. Pelvic adhesions frm endometriosis, appendicitis, prev pelvic sugery
3. tubal occlusion(sterilisation)
4. previous ectopic
5. smoking
6. age
7. IUCD
8. IVF
9. POP

Question 3

Symptoms

Answer 3

Common:
abdo/pelvic pain; amenoorhoea(6-8w frm LMP);’ PV bleed(prune juice/dark red)

Other:
GI Sx, dizziness, collapse, shoulder tip pain, urinary Sx, pain on defecation

Question 4

Signs

Answer 4

Abdo tenderness, cervical motion tenderness. signs of collapse: tachycardia, hypotension, collapse

Question 5

DDx

Answer 5

1. intrauterine pregnancy
2. Appendicitis
3. Miscarriage
4. PID

Question 6

Initial Management

Answer 6

1. Offer pregnancy test
2. Refer to A&E if haemodynamically unstable/concern over degree of pain and bleeding
3. Refer to early pregnancy assessment if Sx&signs of ectopic/pregnancy of 6w or more/uncertain gestation

Question 7

Investigations

Answer 7

1. Serum hCG:
   a) >63% rise 48h apart likely ongoing intrauterine pregnancy. TVUS at 7-14d, earlier if >1500 IU/L
   b) >50% decrease likely non-viable pregnancy. urine pregnancy test 14d later.
   c) if in between either, refer to early pregnancy assessment
2. TVUS to identify pregnancy location, fetal pole and heartbeat.
   - CRL<7.0 mm + X heartbeat, second scan 7d after to confirm miscarriage Dx.
   - mean gestational sac<25.0mm + X fetal pole, second scan 7d after beofre Dx

Question 8

Management

Answer 8

1. Methotrexate
   - X significant pain.
   - Unruptured ectopic, adnexal mass <35mm, X visible heartbeat
   - serum hCG <1500 IU/L
   - X IU pregnancy frm US
   - Follow-up w serial hCG: 2 measurements day 4 and 7, then weekly till negative result. Reasess if plateau or rise.
2. Surgery
   - significant pain
   - adnexal mass >35mm
   - fetal heartbeat on US
   - Serum hCG >5000 IU/L
   - salpingectomy unless risk f for infertility. urine pregnancy test after 3w.
   - if salpingotomy, day 7 serum hCG then weekly till negative.
3. Methotrexate/surgey
   - Serum hCG 1500-5000 IU/L
   - X significant pain, unruptured ectopic <35mm, X visible heartbeat, X intrauterine pregnancy frm US

*anti-D prophylaxis for Rh-ve women having surgery.