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Patho OB 2 > Ectopic Pregnancy > Flashcards

Ectopic Pregnancy Flashcards

1
Q

Question

A

Answer

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2
Q

Implantation anywhere other than this is considered an ectopic pregnancy

A

Endometrial lining of uterine cavity

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3
Q

What type of EP is the most common?

A

Tubal EP - 95%

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4
Q

What type of tubal EP is the most common? What is 2nd most common?

A

Ampulla - 70%
Isthmus - 12%

Fimbria - 11%
Interstial - 2%

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5
Q

What is heterotopic pregnancy?

A

Multifetal pregnancy with one normally implanted and one EP

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6
Q

What confers the highest risk for EP?

A

surgeries for prior tubal pregnancy, for fertility restoration, or sterilization

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7
Q

What is the risk of having an EP when there was a previous EP?

A

5 times

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8
Q

What are the risks for EP?

A 
. 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
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9
Q

What is salpingitis isthmica nodosa?

A

epithelium-lined diverticula extend into a hypertrophied muscularis layer

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10
Q

A female fetus is exposed to diethylstilbesterol in utero. What is a possible consequence for the fetus?

A

Congenital fallopian tube anomaly

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11
Q

What are the possible outcomes for EP?

A

. Tubal rupture
. Tubal abortion
. Pregnancy failure w/ resolution

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12
Q

With EP (proximal/distal) implatations are favored.

A

Distal

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13
Q

What are the possible outcomes for tubal abortion?

A

. 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

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14
Q

What is tubal abortion?

A

When pregnancy passes out of the distal fallopian tube

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15
Q

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.

A

Chronic EP; abnormal trophoblast dies early and thus negative or low static serum B-hCG levels are found

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16
Q

Which has a high serum B-hCG level? Acute or chronic

A

Acute

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17
Q

A pt has delayed menstruation, abdominal pain, and vaginal bleeding. LMP was 8 weeks ago. What is most likely diagnosis?

A

Ectopic pregnancy

The classic triad is delayed menstruation, abdominal pain, and vaginal bleeding or spotting.

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18
Q

What are manifestations of tubal rupture of EP?

A 
. Lower abdominal and pelvic pain
. Bulging posterior vaginal fornix due to collection of blood
. Tender, boggy mass beside uterus
. Enlarged uterus
. Diaphragmatic irritation
. (+) culdocentesis
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19
Q

After a suspected acute hemorrhage, hemoglobin or hematocrit readings are taken. Which is more valuable? Initial reading or serial readings?

A

Serial readings; Hemoglobin or hematocrit may only initiall show a slight reduction

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20
Q

A pt has passed a decidual cast. Did pt have an ectopic pregnancy or abortion? How do you differentiate?

A

EP is no clear gestational sac or villi identified histologically

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21
Q

Why are there increasing rates of EP?

A 
. STD
. early diagnosis for hCG and TVUS
. Certain contraception
. Unsuccessful tubal sterilization
. ART (assisted reproductive technique)
. Induced abortion
. Increased tubal surgery
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22
Q

Define tubal pregnancy

A

pregnancy occuring in the fallopian tube

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23
Q

Define interstial pregnancy

A

pregnancy that implants within the interstitial portion of the fallopian tube

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24
Q

Differentiate and define abdominal pregnancy

A

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

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25
Q

Define cervical pregnancy

A

implatation of the developing conceptus in the cervical canal

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26
Q

Define Ligamentous pregnancy

A

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

27
Q

Define heterotropic pregnancy

A

condition in which ectopic and intrauterine pregnancies coexist

28
Q

Define Ovarian pregnancy

A

EP implants within the ovarian cortex

29
Q

What are the possible outcomes of tubal pregnancy?

A 
. Tubal rupture
. Tubal abortion
. Pregnancy failure
. Tubal abortion
. Acute EP
. Chronic EP
30
Q

Nixon sign vs Dodd’s sign

A

Nixon: unilateral pulsation

Dodd’s: unilateral tenderness

31
Q

What are the key components for EP diagnosis?

A

. Physical finding
. Transvaginal sonography (TVS)
. Serum B-hCG (initial and serial)
. Diagnostic surgery

32
Q

What are the lower limits for ELISA used as pregnancy test?

A

.Urine: 20 - 25 mIU/mL

. Serum < or = 5 mIU/mL

33
Q

What is the important of the Discriminatory Zone?

A

B-hCG levels above which failure to visualize a uterine pregnancy indicates that the pregnancy either is not alive or is ectopic

34
Q

What are the values of the Discriminatory Zone for hCG?

A

. 1500 - 1800 mIU/mL with TVS

. 600 - 6500 mIU/mL with abdominal ultrasound

35
Q

A pt has a serum B-hCG concentration of 1700 mIU/mL and TVS showed an empty uterus. What are the likey differentials?

A

. Failing IUP
. Complete abortion
. EP

36
Q

What is the mean doubling time for serum b-hCG level?

A

48 hours

37
Q

hCG assay are accurate for EP. True or false

A

True. hCG assays positive for 99% of EP

38
Q

A pt has serum progesterone level of 28 ng/mL. Can this be an ectopic pregnancy?

A

No. >25 ng/mL excludes EP

39
Q

A pt has serum progesterone level of 23 ng/mL. Can this be an ectopic pregnancy?

A

Inconclusive. Most ectopic pregnancies have values between 10 and 25 ng/mL.

40
Q

A pt has serum progesterone level of 3 ng/mL. Can this be an ectopic pregnancy?

A

Possibly. <5ng/mL suggests a dead fetus or EP

41
Q

In normal IUP when are the following found with TVS?

GS:
YS:
FP w/ FHR:

A

Gestational Sac: 4.5 to 5 wks
Yolk Sac: 5 to 6 wks
Fetal with fetal heart rate: 5.5 to 6 wks

42
Q

What would be the TVS findings in an EP? What is considered diagnostic?

A 
. 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
43
Q

What would be the TVS findings in an IUP?

A 
. Round
. Eccentric
. Well defined margins
. Intradecidual sign
. Double decidual sac sign
. Growth rate: 0.8 mm/day
44
Q

What are the three most common adnexal findings?

A

. Inhomogenous mass adjacent to the oary - 60%
. Hyperechoic ring - 20%
. Gestational sac with fetal pole - 13%

45
Q

“Ring of fire” was the radiologic finding. What modality was used? Define “ring of fire”. Is this diagnostic?

A

. 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.

46
Q

What are the TVS findings in hemoperitoneum?

A

. anechoic or hypoechoic fluid in the dependent retrouterine cul-de-sac >50ml
. Blood in the Morison pouch near liver (400-700 mL)

47
Q

What are the two ways to asess hemoperitoneum?

A

. TVS

. Culdocentesis

48
Q

Pt was found to have peritoneal fluid + adnexal mass. What is the likely dx? What are some ddx?

A

. EP

. Ascites from ovarian or other cancer

49
Q

How is a culdocentesis performed? What do positive and negative findings mean? What is the significance of clots and clotting? Is it diagnostic?

A

. 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.

50
Q

What is the importance of endometrial sampling? What are the most common findings?

A

. Lack coexisting trophoblast
. 42% decidual reaction
. 22% secretory reaction
. 12% proliferative endometrium

51
Q

What is the most common adnexal mass?

A

corpus luteum

52
Q

What is the importance of laproscopy in EP?

A

Reliable diagnosis due to direct visualization of the fallopian tube and pelvis AND ready transition to operative therapy if needed

53
Q

In evaluation of EP what is the first consideration after presentation of classic traid of symptoms?

A

Determine if pt is hemodynamically stable

54
Q

If pt with classic triad of EP is hemodynamically stable what is the next course of action?

A

TVS

55
Q

If pt with classic triad of EP is NOT hemodynamically stable what is the next course of action?

A

Surgical management

56
Q

If pt with classic triad of EP has a non-diagnostic TVS, what is the next step in evaluation? What are most common findings?

A

. serum b-hCG
. >1500 discriminatory level is ectopic pregnancy
. <1500 discriminatory level = repeat in 48 hours

57
Q

What are the criteria for a expectant management of EP?

A

. 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

58
Q

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?

A

No. Serial b-hCG should be decreasing.

59
Q

What is the MOA of methotrexate in EP?

A

. Folic acid antagonist
. Blocks reduction of dihyrofolate to tetrahydrofolate (active form)
. Purine and pyrimidine synthesis is halted
. Arrest of DNA, RNA, and protein synthesis

60
Q

What is the tubal pregnancy resolution rate for MTX?

A

. 90%

61
Q

What are the adverse effects for MTX for EP?

A

. 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

62
Q

What are the teratogenix effects of MTX?

A

. Craniofacial and skeletal abnormalities, IUGR

63
Q

For single dose MTX, what days do you test B- hCG? What trend are you looking for? What is the management?

A

. Days 4 and 7
. 15% difference
. =/>15% difference, repeat test weekly until undetectable
. <15% difference, repeat MTX and begin new day 1

Patho OB 2 (10 decks)

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