Ectopic Pregnancy Flashcards
Question
Answer
Implantation anywhere other than this is considered an ectopic pregnancy
Endometrial lining of uterine cavity
What type of EP is the most common?
Tubal EP - 95%
What type of tubal EP is the most common? What is 2nd most common?
Ampulla - 70%
Isthmus - 12%
Fimbria - 11%
Interstial - 2%
What is heterotopic pregnancy?
Multifetal pregnancy with one normally implanted and one EP
What confers the highest risk for EP?
surgeries for prior tubal pregnancy, for fertility restoration, or sterilization
What is the risk of having an EP when there was a previous EP?
5 times
What are the risks for EP?
. Surgery . Prior STD . Tubal infection . Peritubal adhesions secondary to salpingitis, appendicitis, or endometriosis . Salpingitis ithmica nodosa . Congenital fallopian tube anomalies . Infertility/ART . Smoking . IUD . Progesterone only contraceptives
What is salpingitis isthmica nodosa?
epithelium-lined diverticula extend into a hypertrophied muscularis layer
A female fetus is exposed to diethylstilbesterol in utero. What is a possible consequence for the fetus?
Congenital fallopian tube anomaly
What are the possible outcomes for EP?
. Tubal rupture
. Tubal abortion
. Pregnancy failure w/ resolution
With EP (proximal/distal) implatations are favored.
Distal
What are the possible outcomes for tubal abortion?
. Hemorrhage may cease and symptoms eventually dissapear
. Bleeding persists as products remain in tube
. Blood pools in rectouterine cul-de-sac (Pouch of Douglas)
. If fimbruated extremity is occluded, hematosalpinx
. Reabsorption
. Reimplantation for become abdominal pregnancy
What is tubal abortion?
When pregnancy passes out of the distal fallopian tube
A pt has a history of EP. Previous test results show that serum B-hCG levels were low at the time. What type of EP did the pt have? Support diagnosis.
Chronic EP; abnormal trophoblast dies early and thus negative or low static serum B-hCG levels are found
Which has a high serum B-hCG level? Acute or chronic
Acute
A pt has delayed menstruation, abdominal pain, and vaginal bleeding. LMP was 8 weeks ago. What is most likely diagnosis?
Ectopic pregnancy
The classic triad is delayed menstruation, abdominal pain, and vaginal bleeding or spotting.
What are manifestations of tubal rupture of EP?
. Lower abdominal and pelvic pain . Bulging posterior vaginal fornix due to collection of blood . Tender, boggy mass beside uterus . Enlarged uterus . Diaphragmatic irritation . (+) culdocentesis
After a suspected acute hemorrhage, hemoglobin or hematocrit readings are taken. Which is more valuable? Initial reading or serial readings?
Serial readings; Hemoglobin or hematocrit may only initiall show a slight reduction
A pt has passed a decidual cast. Did pt have an ectopic pregnancy or abortion? How do you differentiate?
EP is no clear gestational sac or villi identified histologically
Why are there increasing rates of EP?
. STD . early diagnosis for hCG and TVUS . Certain contraception . Unsuccessful tubal sterilization . ART (assisted reproductive technique) . Induced abortion . Increased tubal surgery
Define tubal pregnancy
pregnancy occuring in the fallopian tube
Define interstial pregnancy
pregnancy that implants within the interstitial portion of the fallopian tube
Differentiate and define abdominal pregnancy
Primary - the 1st and only implatation occurs on a peritonieal surface
Secondary - implatation originally in the tubal ostia, subsequently aborted and then reimplanted intothe peritoneal surface
Define cervical pregnancy
implatation of the developing conceptus in the cervical canal
Define Ligamentous pregnancy
a secondary form of EP in which a primary tubal pregnancy erods intot he mesosalpinx and is located between the leaves of the broad ligament
Define heterotropic pregnancy
condition in which ectopic and intrauterine pregnancies coexist
Define Ovarian pregnancy
EP implants within the ovarian cortex
What are the possible outcomes of tubal pregnancy?
. Tubal rupture . Tubal abortion . Pregnancy failure . Tubal abortion . Acute EP . Chronic EP
Nixon sign vs Dodd’s sign
Nixon: unilateral pulsation
Dodd’s: unilateral tenderness
What are the key components for EP diagnosis?
. Physical finding
. Transvaginal sonography (TVS)
. Serum B-hCG (initial and serial)
. Diagnostic surgery
What are the lower limits for ELISA used as pregnancy test?
.Urine: 20 - 25 mIU/mL
. Serum < or = 5 mIU/mL
What is the important of the Discriminatory Zone?
B-hCG levels above which failure to visualize a uterine pregnancy indicates that the pregnancy either is not alive or is ectopic
What are the values of the Discriminatory Zone for hCG?
. 1500 - 1800 mIU/mL with TVS
. 600 - 6500 mIU/mL with abdominal ultrasound
A pt has a serum B-hCG concentration of 1700 mIU/mL and TVS showed an empty uterus. What are the likey differentials?
. Failing IUP
. Complete abortion
. EP
What is the mean doubling time for serum b-hCG level?
48 hours
hCG assay are accurate for EP. True or false
True. hCG assays positive for 99% of EP
A pt has serum progesterone level of 28 ng/mL. Can this be an ectopic pregnancy?
No. >25 ng/mL excludes EP
A pt has serum progesterone level of 23 ng/mL. Can this be an ectopic pregnancy?
Inconclusive. Most ectopic pregnancies have values between 10 and 25 ng/mL.
A pt has serum progesterone level of 3 ng/mL. Can this be an ectopic pregnancy?
Possibly. <5ng/mL suggests a dead fetus or EP
In normal IUP when are the following found with TVS?
GS:
YS:
FP w/ FHR:
Gestational Sac: 4.5 to 5 wks
Yolk Sac: 5 to 6 wks
Fetal with fetal heart rate: 5.5 to 6 wks
What would be the TVS findings in an EP? What is considered diagnostic?
. Trilaminar endometrial pattern (diagnostic) . Anechoic fluid collection (pseudogestational sac and decidual cyst) . Ovoid . Central . Poorly defined margins . Absent decidual reaction . Single decidual layer . No double decidual sac sign
What would be the TVS findings in an IUP?
. Round . Eccentric . Well defined margins . Intradecidual sign . Double decidual sac sign . Growth rate: 0.8 mm/day
What are the three most common adnexal findings?
. Inhomogenous mass adjacent to the oary - 60%
. Hyperechoic ring - 20%
. Gestational sac with fetal pole - 13%
“Ring of fire” was the radiologic finding. What modality was used? Define “ring of fire”. Is this diagnostic?
. Used Doppler color imaging
. increased vascularity resulting in plaental blood flow within the periphery of the complex adnexal mass
. Not diagnostic. Can be EP or corpus luteym cyst.
What are the TVS findings in hemoperitoneum?
. anechoic or hypoechoic fluid in the dependent retrouterine cul-de-sac >50ml
. Blood in the Morison pouch near liver (400-700 mL)
What are the two ways to asess hemoperitoneum?
. TVS
. Culdocentesis
Pt was found to have peritoneal fluid + adnexal mass. What is the likely dx? What are some ddx?
. EP
. Ascites from ovarian or other cancer
How is a culdocentesis performed? What do positive and negative findings mean? What is the significance of clots and clotting? Is it diagnostic?
. Cervis is pulled outward and upward toward the symphysis with a tenaculum, and a long 18-gauge needle is inserted through the posterior vaginal fornix into the retrouterine cul-de-sac.
. (+) fluid containg fragments of old clots or bloody fluid; non-clotting bloody fluid
. (-) unsat entry into the cul-de-sac
. Old clots or non-clotting bloody fluid does not suggest hemoperitoneum; blood samples that clot can be from an adjacent blood vessel or form a brisk ectopic pregnancy.
What is the importance of endometrial sampling? What are the most common findings?
. Lack coexisting trophoblast
. 42% decidual reaction
. 22% secretory reaction
. 12% proliferative endometrium
What is the most common adnexal mass?
corpus luteum
What is the importance of laproscopy in EP?
Reliable diagnosis due to direct visualization of the fallopian tube and pelvis AND ready transition to operative therapy if needed
In evaluation of EP what is the first consideration after presentation of classic traid of symptoms?
Determine if pt is hemodynamically stable
If pt with classic triad of EP is hemodynamically stable what is the next course of action?
TVS
If pt with classic triad of EP is NOT hemodynamically stable what is the next course of action?
Surgical management
If pt with classic triad of EP has a non-diagnostic TVS, what is the next step in evaluation? What are most common findings?
. serum b-hCG
. >1500 discriminatory level is ectopic pregnancy
. <1500 discriminatory level = repeat in 48 hours
What are the criteria for a expectant management of EP?
. Asymptomatic, hemodynamically stable
. Tubal EP
. Decreasing serial b-hCG (esp if initial was =/<1500)
. Small ectopic mass
. No TVS evidence of intra-abdominal bleeding or rupture
. <100 ml fluid in pouch of Douglas
A pt has been diagnosed with tubal EP. She is asymptomatic and hemodynamically stable. Her serial b-hCG shows an increase. Can we use expectant management?
No. Serial b-hCG should be decreasing.
What is the MOA of methotrexate in EP?
. Folic acid antagonist
. Blocks reduction of dihyrofolate to tetrahydrofolate (active form)
. Purine and pyrimidine synthesis is halted
. Arrest of DNA, RNA, and protein synthesis
What is the tubal pregnancy resolution rate for MTX?
. 90%
What are the adverse effects for MTX for EP?
. Harm to bone marrow, GI mucossa, respiratory epithelium
. Toxic to hepatocytes and renally excreted
. Teratogen
.excreted in breast milk and may accumulate in neonatal tissue
What are the teratogenix effects of MTX?
. Craniofacial and skeletal abnormalities, IUGR
For single dose MTX, what days do you test B- hCG? What trend are you looking for? What is the management?
. Days 4 and 7
. 15% difference
. =/>15% difference, repeat test weekly until undetectable
. <15% difference, repeat MTX and begin new day 1
