Ectopic Pregnancy Flashcards
What are the different types of ectopic pregnancies?
Tubal ectopic 97% Most commonly in the ampulla (isthmus most likely to rupture due to lack of space to accommodate enlargement).
Non-tubal Ectopics (ovary, cervix or intrabdominal, uterine (i.e. in myometrium or previous caesarean scar) 2%
Heterotopic Pregnancy twins one in uterus one somewhere else (very rare)
What are the risk factors for ectopic pregnancy?
Progesterone only pill PID Infertility and IVF Pregnancy with an IUD Tubal surgery or pathology - adhesions Smoking – ciliary function Endometriosis Previous ectopic pregnancy Advancing maternal age
What is the common presentation of an ectopic pregnancy?
Triad of Amenorrhoea, Iliac fossa pain and bleeding.
Abdominal pain in right or left iliac fossa, can come in waves, suddenly or gradually
Vaginal bleeding usually spotting
Fainting, dizziness and collapse
Shoulder tip pain – indicating haemoperitoneum
N and V or pain on defecation
Usually presents at 7 weeks after implantation
Cervical excitation and adnexal tenderness
If ruptured:
Abdominal distention
Peritonism
Hypovolaemic shock
What does expectant management for ectopic pregnancy involve and when is it appropriate as 1st line?
Expectant: where clinically stable and pain free, <35mm, no foetal heartbeat and hCG is <1500 and falling. Given 24-hour access to gynae services. Recheck hCG after on days 2, 4 and 7 after the original test. If hCG is falling >15% between at each measurement, then repeat weekly until there is a negative result - <20IU/L. If the value does not decrease by 15% then review for further management.
What does medical management for ectopic pregnancy involve and when is it appropriate as 1st line?
Medical – no significant pain, no evidence of rupture, no foetal heartbeat and adnexalmass <35mm and hCG is <1500 and falling. Methotrexate IM, BhCG measured at 4 and 7 days. Another dose given if BhCG decrease between these days is <15%. Follow up over a month with regular blood tests. 1 in 10 still rupture. No pregnancy for the next 3-6 months
What does surgical management for ectopic pregnancy involve and when is it appropriate as 1st line?
Surgical – significant pain, visible heartbeat, adnexal mass >35mm and hCG >5000 or patient clinically unwell. Laparotomy or laparoscopic procedure. Usually salpingectomy – removal of the fallopian tube but if we need to save the tube or there are other risks of infertility then can do a salpingotomy – incision in the fallopian tube.
When should the women be offered the choice between medical and surgical management of an ectopic pregnancy?
Offer Medical/Surgical if match requirements for medical except that hCG is between 1500 and 5000 IU/L.
How should you manage a suspected ectopic that can’t be confirmed?
If Ectopic can’t be confirmed, then wait and rescan within 7 days
What other consideration should be taken when managing ectopic pregnancy?
Consider psychosocial impact of pregnancy loss and answer any questions, reassure mother it was not anything she did wrong.
Anti D if any intervention and Rh negative also in women past 12 weeks with any bleeding.
