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)
When would salpingotomy be preferred?
Other tube not healthy/absent to preserve chance of future intrauterine pregnancy
Why follow up women with hx of salpingotomy?
Need serum hCG to detect and treat persistent trophoblast early (if woman is stable, consider methotrexate)
Ensure woman has had Anti-D if necessary and discuss implications on future fertility
