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A - MSRA Gynaecology > Ectopic Pregnancy > Flashcards

Ectopic Pregnancy Flashcards

1
Q

What is an ectopic pregnancy?

A

Any pregnancy which is implanted at a site outside of the uterine cavity

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2
Q

What are the most common sites of implantation in ectopic pregnancy?

A

Ampulla and isthmus of the fallopian tubes

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3
Q

What are the less common sites of implantation in ectopic pregnancy?

A
  • Ovaries
  • Cervix
  • Peritoneal cavity
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4
Q

What is the rate of ectopic pregnancy in the UK?

A

11 in 1000 pregnancies

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5
Q

What is the mortality rate in ectopic pregnancy?

A

~ 0.2 per 100

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6
Q

What proportion of ectopic pregnancy mortalities are due to substandard care?

A

2/3

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7
Q

What proportion of women with ectopic pregnancy do not have any known risk factors?

A

1/3

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8
Q

What are some known risk factors for ectopic pregnancy?

A
  • Past medical history factors
  • Contraceptive factors
  • Iatrogenic factors
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9
Q

What are the past medical history risk factors for ectopic pregnancy?

A
  • Previous ectopic pregnancy
  • PID
  • Endometriosis
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10
Q

What are the contraceptive risk factors for ectopic pregnancy?

A
  • IUD or IUS
  • Progesterone oral contraceptive or implant
  • Tubal ligation or occlusion
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11
Q

Why can PID and endometriosis lead to ectopic pregnancy?

A

Due to adhesion formation

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12
Q

Why can progesterone oral contraceptive or implant lead to ectopic pregnancy?

A
  • Due to fallopian tube ciliary dysmotility
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13
Q

What are the iatrogenic risk factors for ectopic pregnancy?

A
  • Pelvic surgery - especially tubal

- Assisted reproduction

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14
Q

What is an example of a tubal surgery that can lead to higher risk of ectopic pregnancy?

A

Reversal of sterilisation

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15
Q

What are the most common symptoms of ectopic pregnancy?

A
  • Abdominal pain
  • Pelvic pain
  • Amenorrhoea or missed period
  • Vaginal bleeding with or without clots
  • Vaginal discharge
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16
Q

How does discharge in ectopic pregnancy appear?

A

Brown, and like prune juice

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17
Q

What causes the brown discharge in ectopic pregnancy?

A

The decidua breaking down

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18
Q

What are some other symptoms of ectopic pregnancy?

A
  • Dizziness, fainting or syncope
  • Breast tenderness
  • Shoulder tip pain
  • Urinary symptoms
  • GI symptoms such as diarrhoea and/or vomiting
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19
Q

What may be seen on examination in ectopic pregnancy?

A
  • Localised abdominal tenderness

- Vaginal examination reveals cervical excitation and/or adnexal tenderness

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20
Q

What may be seen in the patient if the ectopic pregnancy has ruptured?

A

Signs of haemodynamic instability and/or signs of peritonitis

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21
Q

What are some signs of haemodynamic instability?

A
  • Pallor
  • Increased CRT
  • Tachycardia
  • Hypotension
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22
Q

What are signs of peritonitis?

A
  • Rebound tenderness

- Guarding

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23
Q

Why may the amount of vaginal bleeding be misleading in ruptured ectopic pregnancy?

A

Blood will mostly enter the pelvis and so vaginal bleeding may be minimal

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24
Q

What are the differentials for ectopic pregnancy?

A
  • Miscarriage
  • Ovarian cyst accident
  • Acute PID
  • Appendicitis
  • Diverticulitis
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25
Q

What are the first line tests for suspected ectopic pregnancy?

A
  • Urine pregnancy test

- Pelvic USS

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26
Q

Which investigation is most important in first assessing ectopic pregnancy?

A

Urine pregnancy test

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27
Q

When should a pelvic USS be performed in suspected ectopic pregnancy?

A

If pregnancy test is positive

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28
Q

What can pelvic USS show in suspected ectopic pregnancy?

A

Presence or absence of intrauterine pregnancy

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29
Q

What should be offered if transabdominal USS cannot identify an intrauterine pregnancy?

A

Transvaginal USS

30
Q

What is the term used for a positive urine beta-HCG but not identifiable pregnancy on USS?

A

Pregnancy of unknown location

31
Q

What are the 3 possible differentials for pregnancy of unknown location?

A
  • Very early intrauterine pregnancy
  • Miscarriage
  • Ectopic pregnancy
32
Q

What additional test should be taken in pregnancy of unknown location?

A

Serum beta-HCG

33
Q

What is assumed if serum beta-HCG for pregnancy of unknown location is >1500 iU

A

Ectopic pregnancy until proven otherwise

34
Q

What should be offered if serum beta-HCG suggests ectopic pregnancy?

A

Diagnostic laparoscopy

35
Q

What should be done if initial serum beta-HCG for pregnancy of unknown location is <1500 iU?

A

A further serum beta-HCG 48 hours later

36
Q

What would happen to the serum beta-HCG level over 48 hours if there is a viable pregnancy?

A

It should double

37
Q

What would happen to the serum beta-HCG level over 48 hours if there is a miscarriage?

A

It should halve

38
Q

When can an ectopic pregnancy not be excluded based on serial serum beta-HCG result?

A

If there is less than a double or half in the level over 48 hours

39
Q

Where should any patient with a suspected ectopic pregnancy be managed?

A

In hospital

40
Q

What may be needed if the patient is systemically unwell?

A

A-E approach to resuscitation possible including blood products

41
Q

What are the three types of definitive management for ectopic pregnancy?

A
  • Conservative
  • Medical
  • Surgical
42
Q

What does conservative management of ectopic pregnancy involve?

A

Watchful waiting of the stable patient while allowing the ectopic to resolve naturally

43
Q

Is conservative management of ectopic pregnancy first line?

A

No, it is only suitable for a small number of patients and should be discussed at a senior level

44
Q

What should be performed to monitor progress of conservative management of
ectopic pregnancy?

A

Serum beta-HCG every 48 hours to ensure it is falling by at least 50% every 48 hours

45
Q

At what level is beta-HCG satisfactory in conservative management of ectopic pregnancy?

46
Q

Who can conservative management for ectopic pregnancy be offered to?

A
  • Unlikely to rupture
  • Stable
  • Well controlled pain
  • Low baseline beta-HCG
  • Small, unruptured ectopic on USS
47
Q

What advice should be given to patients having conservative management of ectopic pregnancy?

A
  • 24/7 access to gynae services

- Informed of symptoms of rupture

48
Q

What are the advantages of conservative management of ectopic pregnancy?

A
  • Avoids risks of medical and surgical management

- Can be done at home

49
Q

What are the disadvantages of conservative management of ectopic pregnancy?

A
  • Failure or complications may necessitate need for surgery or medical management
50
Q

What percentage of patients receiving conservative ectopic pregnancy management require surgical or medical intervention?

51
Q

What is the medical management of ectopic pregnancy?

A

IM methotrexate

52
Q

How does methotrexate work to treat ectopic pregnancy?

A

It is an anti-folate cytotoxic agent that disrupts folate dependent cell division of the developing fetus

53
Q

What monitoring should a patient on methotrexate for ectopic pregnancy receive?

A

Regular serum beta-HCG to ensure levels decline

54
Q

What is done if beta-HCG levels don’t decline after initial dose of IM methotrexate in ectopic pregnancy?

A

Administer another

55
Q

Who can receive methotrexate to treat ectopic pregnancy?

A
  • Stable patients
  • Well controlled pain
  • Beta-HCG <1500iU/ml
  • Ectopic pregnancy unruptured without visible heartbeat
56
Q

What advice should women undergoing medical management of ectopic pregnancy be given?

A
  • 24/7 access to gynae services

- Symptoms of rupture

57
Q

What are the advantages of medical management of ectopic pregnancy?

A
  • Avoids complications of surgery

- Patient can be at home after injection

58
Q

What are the disadvantages of medical management ectopic pregnancy?

A
  • Potential side-effects of methotrexate
  • Teratogenic and so patients should use contraception for 3-6 months after
  • Treatment can fail - need surgery
59
Q

What are the potential side-effects of methotrexate?

A
  • Abdominal pain
  • Myelosuppression
  • Renal dysfunction
  • Hepatitis
60
Q

What is involved in surgical management of ectopic pregnancy?

A

Surgical removal of the ectopic (this seems a bit too obvious but I’ll leave it in)

61
Q

What is the usual procedure for a tubal ectopic?

A

Laparoscopic salpingectomy

62
Q

What happens in a laparoscopic salpingectomy for tubal ectopic?

A

Removal of the tube the fetus is implanted in

63
Q

If there is damage to the contralateral tube what alternative procedure can be considered to preserve fertility?

A

Salpingotomy

64
Q

What follow-up is require in a salpingotomy for ectopic pregnancy?

A

HCG testing until <5iU

65
Q

What happens to the risk of future ectopic pregnancy in the tube that underwent salpingotomy?

66
Q

When is surgical management of ectopic pregnancy considered?

A
  • Severe pain
  • Serum beta-hCG >5000mlU/ml
  • Adnexal mass >34mm
  • Visible fetal heart beat
67
Q

What are the advantages of surgical management of ectopic pregnancy?

A
  • Reassurance of definitive treatment

- High success rate

68
Q

What are the disadvantages of surgical management of ectopic pregnancy?

A
  • GA risk
  • Risk of damaging neighbouring structures
  • Risk of treatment failure with salpingotomy
69
Q

What structures are at risk in surgical management of ectopic pregnancy?

A
  • Bladder
  • Bowel
  • Ureters
  • DVT/PE
  • Haemorrhage
  • Infection
70
Q

Why may a salpingotomy fail at treating ectopic pregnancy?

A

Some pregnancy may remain

71
Q

What should all Rh -ve women receive before surgical management of ectopic pregnancy?

A

Anti-D prophylaxis

72
Q

What are the potential complications of ectopic pregnancy?

A
  • Tubal or uterine rupture
  • Massive haemorrhage
  • Shock
  • DIC
  • Death

A - MSRA Gynaecology (52 decks)

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