Ectopic pregnancy

Question 1

What are the likely sites of ectopic pregnancy?

Answer 1

Ovaries

Fimbriae of fallopian tube

Ampulla of fallopian tube

Isthmus of fallopian tube

Upper horns of the uterus - cornual ectopic

Cervix

Abdomen

Question 2

Why is the number of ectopic pregnancies rising?

Answer 2

Due to the increasing number of cases of PID and increasing number IVF users.

Question 3

What is the current incidence of ectopic pregnancies in the UK?

Answer 3

1 ectopic for every hundred term deliveries

Question 4

What are the risk factors for ectopic pregnancy?

Answer 4

PID

Tubal surgery eg sterilisation or reversal of sterilisation, previous ectopic surgery

Peritonitis or pelvic surgery eg appendicitis

IUCD in situ (coil)

IVF

Endometriosis

Progesterone only pill - if patient does conceive while on the mini pill then they are more at risk of ectopic.

Question 5

What are the symptoms of ectopic pregnancy?

Answer 5

Abdominal pain

Bleeding - if ruptured

Shoulder tip pain

Pain when going to the loo

Nausea and diarrhoea

Missed period

Positive pregnancy test

Question 6

What investigations should be done for someone with acute abdominal pain and bleeding in whom you suspect an ectopic pregnancy?

Answer 6

FBC

Serum hCG

Ultrasound - to demonstrate an empty uterus

Laparoscopy - once haemodynamically stable

Question 7

How might serum hCG help with the differential diagnosis of vaginal bleeding in a pregnant woman?

Answer 7

Two serum hCG tests should be performed 48 hours apart

A viable pregnancy will show a rise in hCG of > 66%

A miscarriage will show a fall in hCG

An ectopic will show a plateau in the levels of hCG

Question 8

How do we manage patients with ectopic pregnancy?

Answer 8

Surgically -

Medical treatment -

Question 9

What conditions must be met for medical (rather than surgical) treatment of ectopic pregnancy to be considered?

Answer 9

Asymptomatic

Small pregnancy - less than 3 cm measured on USS

Intact tubal

No cardiac activity

hCG less than 3000 iu/L

Question 10

How do we follow up patients who have been treated for ectopic pregnancy?

Answer 10

Serum hCG must be checked at various points over the following days to make sure there is a downward trend.

Question 11

What are the complications of treatment for ovarian ectopic pregnancy?

Answer 11

Recurrence if management was conservative (ie not salpingectomy)

Lower chance of conception with salpingectomy)

Question 12

What are the complications of untreated ectopic pregnancy?

Answer 12

Fallopian rupture and massive haemorrhage

Question 13

Surgical management of Ectopic pregnancy

Answer 13

Surgically -
salpingectomy (removal of the affected fallopian tube and ovary)
salpingotomy (removal of the ectopic pregnancy from the fallopian tube.

Question 14

Medical management of Ectopic pregnancy

Answer 14

1. IM methorexate

2. Measure HCG at 4 and 7 days

Question 15

Gold standard investigation for ectopic

Answer 15

Laproscopy