Ectopic Pregnancy

Question 1

Define Ectopic Pregnancy

Answer 1

Implantation of an embryo outside of the uterine cavity

Question 2

Incidence of EP

Answer 2

1.5%. If hx of EP = 10%

Question 3

Causes of EP

Answer 3

Scarring/Adhesions:

• PID
• Endometriosis
• Pelvic surgery
• Sterilisation

IVF:
- Anyone with assisted contraception at risk of EP because reverse flow of cilia

IUD: overall decrease chance but if conceive, will increase

Cilia dysfunction: Smokers

Question 4

Risk factors of EP

Answer 4

Maternal Age
Social:
- Smoking
- Low SES

Gynae: Subfertility, past hx of ectopics

Question 5

Possible sites of EP

Answer 5

Tubes - most commonly infundibulum & ampulla
Scar - previous section
Ovary

Question 6

Why is EP a problem

Answer 6

tube cannot support the invasion of the trophoblastic embryo tissue. Will rupture at 8 weeks.

Question 7

Symptoms of EP

Answer 7

Most are asymptomatic. But watch for these symptoms:

• Lower abdo pain, colicky then generalised
• Shoulder tip pain
• Diarrhoea (bowel irritation)
• Vaginal bleeding - small amount (HCG thickens the endometrium)

Question 8

Findings on digital vaginal exam

Answer 8

1. Os is close. If open = not EP
2. Cervical motion tenderness.
3. Feel for masses

Question 9

What should the serum bEHCG be for EP (absolute & serial)

Answer 9

Absolute > 1500 + empty uterus (must be empty)
Serial:
- Plateu or rise (normal pregnancy will double in the 1st 10 weeks)

Question 10

EP bleeds into where

Answer 10

Peritoneal cavity (not the vaginal because tubes are intraperitoneal)

Question 11

When should a pregnant mother present for scans if she has a hx of EP

Answer 11

6-8 weeks in the early pregnancy assessment unit (EPAU)

Question 12

3 management types for Ep

Answer 12

Expectant, Medical, Surgical

Question 13

What is expectant management. What are the criteria

Answer 13

Allow EP to resolve spontaneously.
Cannot have pain & HCG < 1000 & decreasing

Need to follow up bHCG until its 0

Question 14

What is medical management? What are the criteria

Answer 14

Methotrexate. Inhibit DNA synthesis. 1 IM injection.

Criteria: ALL must be met

• No pain
• Adnexal mass < 35mm
• No foetal heart beat
• bHCG < 1500
• no free fluid

Follow HCG until 0. Use reliable contraception for 3 months.

Question 15

What is surgical management? What are the criteria

Answer 15

Salpingectomy (unless fertility sparing then salpingotomy). Remove whole tube

Criteria: Any of the criteria

• Unstable/Pain
• Adnexal mass > 35mm
• Foetal Heart beat present
• Free fluid present
• serum HCG > 5000

recheck HCG for 3 weeks

Question 16

Contraindications for medical managment

Answer 16

Liver problems or heteropregnancy

Question 17

Caution for surgical managemnet

Answer 17

BMI > 45. Surgical risk, coagulopathy

Question 18

What is the failure rate for medical management

Answer 18

15%, need repeat injection

Question 19

Do you have to give Anti-D for EP

Answer 19

Yes. Even if less than 12 weeks.

Question 20

What gestational age does EP classically present

Answer 20

4-8 weeks

Question 21

When do you decide that medical managemnet is not working?

Answer 21

Complications or after 2 rounds, EP still present