Ectopic Pregnancy Flashcards
In which contraceptive methods is an ectopic pregnancy more likely to occur?
- Progestin only oral contraceptive or progestin only implants or IUCD
What are the risk factors that lead to the development of ectopic pregnancy?
Woman:
- Smoking
- Above 40
- Diethylstilboestrol exposure
- Sexual promiscuity
Tubal:
- Documented Tubal pathology
- Sterilisation
- Previous Genital infection
- Previous tubal surgery
Previous pregnancy:
- Previous ectopic, miscarriage or abortion
- Assisted pregnancy
What is the earliest confirmation of an intra-uterine pregnancy on ultrasound?
- A gestational sac surrounded by a double echogenic ring (deciduous capsular is and parietalis)
What is the triad that diagnoses ectopic pregnancy?
- Lower abdominal pain
- , amenorrhea
- Vaginal bleeding
What percentage of ectopic pregnancies have no symptoms?
9%
What are the 3 factors that help us diagnose ectopic pregnancy?
- Clinical
- B-hCG
- Transnational ultrasound
How do ectopic pregnancies differ when it comes to the rise of the B-HCG?
It rises much slower than intra-uterine pregnancies and tends to be lower
What is highly suggestive of an ectopic pregnancy on transvaginal ultrasound?
Empty uterus with free fluid in the pouch of Douglas and complex cystic mass
What is the discrimatory zone?
It is the lowest level of B-hCG that is used to estimate when we will be able to see a viable pregnancy on ultrasound
This is usually 1500 IU
What are the other serum markers that we use to diagnose ectopic pregnancy?
- Progesterone
>22 then it is a intra-uterine pregnancy
<15 ectopic - PAPP-A(Pregnancy associated plasma protein A)
- CK(Creatinine kinase)
- CA125
- VEGF(vasoactive endothelial growth factor)
What is the management of a patient with an unruptured ectopic pregnancy?
- Expectant therapy (watchful waiting)
- Medical
- Surgery
What does expectant therapy entail?
The patient is offered this if the initial B-hCG level is <175 IU
- the bhcg is decreasing
- there is no evidence of a ruptured ectopic pregnancy
- the BHCG is <1000
What must the patient do in order to do expectant therapy well?
The patient must be willing to abstain from sex
The patient must be willing to come in twice a week for BHCG check ups
What is the gold standard medical treatment for ectopic pregnancy?
Methotrexate 1mg/kg IM
What are the other agents we can give the patient that are not good at working alone?
- hyperosmolar glucose
- potassium chloride
When do we consider medical treatment?
- If there is no rupture and they are haemodynamically stable
- Have B-hcg levels of less than 3000 IU
- Make sure there is no foetal cardiac activity
- And they must have normal FBC,LFT, UE bloods
What is the single dose regimen of medical management?
Methotrexate 1mg/kg IM
And repeat doses of methotrexate if the BHCG is not <15% after 4-7 days
How many maximum doses of methotrexate do you use in medical management?
4 doses
What is the multi dose regimen for the management of unruptured ectopic pregnancy?
- Start with methotrexate 1mg/kg one day 1,3,5,7
- Then give 0,1mg/kg dose of leucovorin on day 2,4,6,8
- Continue until the bhcg drops by >15 in 48 hours
- Repeat course if the concentration is not 40% of the original by day 14
How long should women avoid pregnancy after methotrexate use?
3 months because it is teratogenic
What are the indications for surgery in an unruptured ectopic pregnancy?
- BHCG of >3000IU
- Cardiac activity
- Heterotopic pregnancy (IUP with ectopic pregnancy)
4.
How do we decide between a salpingotomy and a salpingectomy?
- We do a salpingostomy when we have a pathological contralateral Fallopian tube and we want to preserve the moms fertility
- We can do either a salpingostomy or salpingectomy if the contralateral tube is healthy
When do we decide to do a laparoscopy?
If the patient is haemodynamically unstable
