Ectopic pregnancy Flashcards
What is ectopic pregnancy?
implantation of fertilised ovum outside of the uterus
What are risk factors for ectopic pregnancy?
Anything slowing the ovum's passage to the uterus: Damage to the tubes: Pelvic inflammatory disease Previous surgery esp tubal ligations Previous ecotpic Endometriosis IUCD POP Subfertility and IVF Smoking
Where do ectopic pregnancies occur?
97% tubal, mostly in ampulla
25% in narrow inextensible isthmus
3% in ovary, cervix or peritoneum
What are clinical features of ectopic pregnancy?
Abdominal pain (lower, constant, may be unilateral - due to tubal spasm)
Vaginal bleeding: usually less than normal period, may be dark brown
Amenorrhoea 6-8 weeks
Peritoneal bleeding can cause shoulder tip pain or pain on defection or urination
Diarrhoea, loos stools, vomtiing
Dizziness
Collapse
What are examination features?
Abdominal tenderness
Normal sized uterus
Cervical excitation - examining cervix will not rupture pregnancy
Peritonitis
What investigations for ectopic pregnancy?
FBC
Group and save - crossmatch if unstable
Serum progesterone to identify failing pregnancy
hCG > 1500IU
Transvaginal ultrasound scan
Laparoscopy may be necessary in unknown location
Urinary pregnancy test b-hCG If positive - TVUS IF there is no fetus seen on TVUS: Pregnancy of unknown location 1. Early pregnancy 2. Miscarriage 3. Ectopic pregnancy
Do serum b-hCG
IF >1500 ectopic pregnancy
–> Diagnostic laprascopy
IF <1500: Do further serum hCG in 48h If miscarriage: halves every 48h If pregnancy: doubles every 48h If neither of these patterns - may be ectopic
What are criteria for expectant management?
Size < 30mm Unruptured Asymptomatic No fatal heart beat B-hCG < 200IU/L and declining No haemoperitoneum Compatible if another intrauterine pregnancy
What is expectant management? Advantages/disadvantages?
Closely monitor b-hCG over 48 hours to ensure it is falling by equal to or greater 50% of the level
If B-hCG rises or symptoms manifest, intervention is performed
Advantages: Avoid the risks of medical and surgical management, can be done at home.
Disadvantages: Failure or complications necessitating medical or surgical management (25% of patients), rupture of ectopic
What is the criteria for medical management?
Size < 35mm Unruptured No pain No fetal heartbeat Serum B-hCG < 1500IU/L Not suitable if intrauterine pregnancy
What is medical management for ectopic pregnancy? What advise should you give afterwards? Side effectS?
Advantages
Disadvantages?
Methotrexate as a sign dose
hCG levels on days 4 and 6
If hCG has fallen by < 15%, repeat dose is given
Methotrexate is teratogenic and women should use reliable contraception for 3 months afterwards
SE: conjunctivitis, stomatitis, diarrhoea, abdominal pain
Advantages: Avoids the complications of surgical management and the patient can be at home after the injection.
Disadvantages: Potential side effects of methotrexate – abdominal pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (patients must be advised to use contraception for 3-6 months after methotrexate use). The treatment can fail, which would necessitate surgical intervention.
What are criteria for surgical management?
Size < 35mm Can be ruptured Severe pain Visible fetal heartbeat Serum B-hCG > 1500IU/L Compatible with another intrauterine pregnancy
What is surgical management for ectopic?
Advantages and disadvantages?
Laparoscopy
Laparotomy
With salpingectomy - removal of tube
Salpingotomy - removal of ectopic through a tubal incision
laparoscopic salpingectomy is usually performed
Advantages: Reassurance about when the definitive treatment can be provided, high success rate.
Disadvantages: General anaesthetic risk, risk of damage to neighbouring structures like the bladder, bowel, ureters, DVT/PE, haemorrhage, infection. With salpingotomy, there is also a risk of treatment failure – as some of the pregnancy may remain within the tube.
What is the preferred surgical treatment option: laparoscopy or laparotomy?
Laparoscopy: Reduced operating time Reduced length of stay Reduced analgesia Less blood loss Quicker reecovery
When do you do salpingectomy?
Removal of whole tube
If the contralateral tube is healthy
Salpingotomy is primary treatment if the other tube is not healthy to preserve change of furniture intrauterine pregnancy but warn risk of future ectopic pregnancy.
How should you follow up women who have salpingotomy?
Serum BhCG to detect and treat persistent trophoblast
