Ectopic Pregnancy

Question 1

Approaching Ectopic Pregnancy

Answer 1

All women for Reproductive age are pregnant unless proven otherwise; All
women with Positive Pregnancy test considered Ectopic unless clearly
demonstrated to be Intrauterine

Question 2

Definition of Ectopic

Answer 2

Implantation of Conceptus outside of Uterine Cavity; 1 – 2% of pregnancies
o Most commonly Tubal (98%);
Remainder Abdominal,
Ovarian, Cervical and rarely within C-section scars
o Early presentations because of EPAU

Question 3

Symptoms of Ectopic Pregnancy

Answer 3

Often Asymptomatic; Amenorrhoea (usually 6 – 8/52), Pain (Lower Abdominal, often Mild and
Vague; Classically unilateral), Vaginal Bleeding (Often brown), Diarrhoea and Vomiting; Dizziness and Lightheadedness, Shoulder Tip Pain, Collapse (If Ruptured Ectopic)
o Tend to have poor PPV to discriminate Intra and Extrauterine Pregnancy
o Majority will be clinically stable and well, with minimal symptoms and signs

Question 4

Signs of Ectopic Pregnancy

Answer 4

Often no specific signs; Normal sized Uterus; Cervical Excitation and Adnexal Tenderness occasionally; Adnexal mass very rarely
o Can present as Acute Abdomen – Peritonism due to Intra-Abdominal Blood

Question 5

Risk Factors for Ectopic Pregnancy

Answer 5

Infertility, Assisted Conception, PID, Endometriosis, Pelvic or Tubal Surgery,
Precious Ectopic (Recurrence 10 – 20%), IUD In-situ, Smoking
o Majority, however, will have obvious risk factors

Question 6

Differentials

Answer 6

Differentials include Miscarriage, Bleeding Cyst, Ovarian Pathology or PID

Question 7

Investigations for Ectopic Pregnancy

Answer 7

TVUS-Establish location, presence of adnexal mass or free fluid
Serum progesterone: distinguish whether failing
Serum B-HCG: Repeated 48hrs later-suboptimal rise suspicious but not diagnostic
Laparoscopy is gold standard but only if necessary for clinical reasons or if not on TV USS

Question 8

Pregnancy of Unknown Location

Answer 8

No sign of IUP or Ectopic, or RPOC in the presence of Positive Pregnancy Test or hCG >5

Question 9

Reasons for pregnancy of unknown location

Answer 9

Early IUP, Failing or Persisting PUL, Ectopic Pregnancy (10% of PUL), Complete Miscarriage, Extremely rarely due to hCG secreting tumours

Question 10

Clinical Features of PUL

Answer 10

Symptoms and Clinical presentation most important; Significant Pain, Tenderness,
Haemoperitoneum usually require Laparoscopy

Question 11

How to manage an ectopic pregnancy

Answer 11

Expectant and Medical Management if Clinically stable, Asymptomatic/Minimal symptoms,
hCG <3000IU, <3cm, No Foetal Cardiac Activity, No Haemoperitoneum, Able to access hospital quickly, Unlikely to default on Follow-up

Question 12

Managing expectant ectopic pregnancy

Answer 12

Suitable if hCG falling; Every 48h until repeated fall in level; Monitor Weekly until
<15IU; If Plateau, can wait for decline as long as clinically well

Question 13

Medical Management

Answer 13

Methotrexate IM 50mg/m2
; hCG measured on days 4 and 7; Another
dose required if decline is less than <15% between days 4 and 7
o Should use reliable contraception for 3/12 after due to Teratogenic effects
o SE: Conjunctivitis, Stomatitis, Gastrointestinal Upset

Question 14

Surgical Management

Answer 14

Laparoscopic unless Haemodynamically unstable; Salpingectomy preferable if contralateral adnexa normal; Lower rates of Persistent Trophoblast and
recurrent Ectopic while same pregnancy rates after