Ectopic pregnancy Flashcards
Green
Definition
Implantation of embryo outside of uterine cavity
Most common site
Fallopian tubes 95%, mostly in ampulla but 25% occur in isthmus (although can occur in cornu, cervix, ovary, abdo cavity)
Predisposing factors?
Any damage to tube causing ovum to be caught, including:
Damage to tubes (PID, prev surgery - sterilisation, reversal, surg to improve fertility etc, tubal ligation - 9 times more likely to get ectopics)
Previous ectopic
Endometriosis
Contraceptives (IUCD, POP)
Subfertility and IVF
Smoking
Red flag symptoms?
In sexually active woman: Abnormal vaginal bleed, collapse, abdominal pain, diarrhoea and vomiting = perform pregnancy test
Symptoms in history?
Lower abdo pain (classically unilateral) followed by dark, scanty vaginal bleed(may not be concomitant)
Syncopal episodes + shoulder tip pain - indicates intraperitoneal blood loss
Diarrhoea, loose stools and/or vomiting (less acute, more chronic)
Amennorhoea normal (but if pt unaware of pregnancy, may interpret bleed as period)
May be asymptomatic - ask LMP
Signs on examination?
Tachycardia from blood loss (hypotension and collapse rare, extreme sign)
Peritonitis/abdo rebound tenderness
Cervical excitation (pain on movement of uterus)
Smaller uterus than expected and Os closed
Adnexal mass (rare)
Ix?
Urine hCG (+/- serum hCG)
USS (preferably TVS, not transabdo) for intrauterine ectopic (if negative - too early in gestation, complete miscarriage occurred, pregnancy elsewhere); also look for adnexal blood clot, free blood, empty gestation sac.
Quantitative serum hCG if uterus empty
FBC and G&S
Serum progesterone to identify a failing pregnancy
Laproscopy as last resort (esp for PUL)
A woman who conceives while using what contraception must have ectopics excluded urgently?
Copper coil - this prevents most intrauterine pregnancies but not those implanting in the tubes
Management of symptomatic suspected ectopic
Nil by mouth FBC + cross match 6 units blood Pregnancy test USS Laproscopy or consider medical management if criteria met IV access Anti-D given if pt Rh negative
Management of acute presentation (haemodynamically unstable)
Resuscitation and surgery (laparotomy for salpingectomy typically)
Management of subacute presentation
Expectant if: (see M) Medical if: -asymptomatic/mild symptoms -hCG <3000 -ectopic <3mm on scan (without foetal heart) -no haemoperitoneum Surgical
Expectant management
Only in v low risk pts (above criteria + falling hCG). Take hCG measures 48hrly until fall confirmed, then weekly monitoring until <15. Plateau/slow rise hCG needs specialist referral
Medical management
Methotrexate used as singe dose (50mg/m2 IM) with hCG levels on days 4 and 7. If hCG falls by <15%, repeat dose given.
Methotrexate is teratogenic, so woman should use reliable contraception (condom) for 3 months.
Side effects: conjunctivitis, stomatitis, diarrhoea, abdo pain.
Outcomes with methotrexate similar to surgical management
Surgical management
Laparoscopy preferable, but nature of acute presentation means laparotomy more typical. If suspected rupture of ectopic - recruit senior help.
If woman has had previous salpingectomy and requires similar treatment - inform her, and discuss future briefly (IVF etc)
Why are salpingectomies performed over salpingotomy?
Only 15% reduction in fertility and risk of ectopic substantially less than salpingotomy (incision and repair causes scar tissue, easier for future ova to become stuck)
