Ectopic Pregnancy **** Flashcards
What is it?
Implantation of a fertilised egg outside of the uterus
Where do they usually take place?
Tubal - ampulla
The remainder in ovaries, cervix and peritoneum
Why can you get tubal rupture?
Trophoblast invasion of the tubal wall
This can lead to major haemorrhaging
Risk factors?
Previous ectopic, PID or Surgery
IUCD in situ
Ovulation induction - fertility Rx
Past history of ectopics
Presentation:
How long after LMP does it tend to present?
2 main symptoms?
6-8 wks after LMP
(1) PV bleeding (dark or fresh) which can occur with or without rupture
OR
(2) Abdo/pelvic pain
Presentation:
Where else do they get pain that may seem odd?
What may be elicited on a vaginal examination?
Other features? - 2
What might indicate sudden rupture?
Shoulder tip pain - indicates some internal bleeding
Cervical excitation - Gently move the cervix from side to side to check for cervical tenderness (important sign with ectopic pregnancy or pelvic inflammatory disease).
D&V
Syncope and dizziness
Sudden, severe pain
Peritonism and shock
Investigations:
Bedside?
Imaging to find viable intrauterine pregnancy or to visualise ectopic embryo?
What if the above can’t anything, what is that called?
What blood test is done if no intrauterine pregnancy is confirmed on imaging?
Other blood that should be done if they might need surgery?
Urine Beta-hCG positive
TVUS - abdo US alternative
‘Pregnancy of unknown location’ - Follow up needed
Serum beta-hCG
Falling values suggest miscarriage
Slow rising values suggest ECTOPIC - re-review in 24 hrs
FBC
Group and save
Management - Conservative:
What is the maximum ectopic mass size before medical Rx is used? What about the foetus needs to be absent?
How should they be followed up - 2 things?
<3.5 cm + NO heartbeat
<1000 IU/L and FALLING
Ensure adnexal mass shrinks and beta-hCG drops every 48 hours
Management - Medical:
What is given for pain?
Drug used?
Route?
What do they need contraception for 3 months after starting this drug?
Indications:
- Same criteria as conservative but the beta-hCG is at a higher level. Under what level should Beta-hCG be though?
Analgesia
Methotrexate IM
Teratogenic effects
<1500 IU/L
If indications not met (due to increased risk of rupture)
+
Usual MTX side CIs - cytopenia, PUD, liver disease
Common side effects of methotrexate include:
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
Management - Surgical:
Indications
2 procedures - what are they?:
- Salpingectomy *****
- Salpingotomy - why may this be done knowing the risks? What are the risks?
Unstable
Significant pain
Methotrexate contraindicated
—–
Tube removal
Dissecting the ectopic if there is only healthy tube remaining
Future ectopics due to adhesions and scar tissue
Pregnancy of unknown location:
Define
Outcomes - list a few
Management of:
- Significant pain and haemoperitoneum
- Well with no haemoperitoneum, beta-hCG and progesterone on the first day of the scan
What should be used to help guide the management?
No signs of IU/ectopic pregnancy/retained products of conception in the presence of the +ve preg test
Early IU pregnancy (too early to scan)
Complete miscarriage
Falling PUL
Ectopic pregnancy
Persistent PUL
hCG - secreting tumour
Laparoscopy
Followup and repeat 48 hrs later
LOCAL GUIDELINES
