Ectopic Pregnancy

Question 1

What is an ectopic pregnancy?

Answer 1

Any pregnancy that develops outside the endometrial cavity

Question 2

They affect how many pregnancies?

Answer 2

1 in 90

Question 3

The vast majority, 97%, occur where?

Answer 3

Fallopian tube

Question 4

What are the most common sites of the Fallopian tube that are most often affected?

Answer 4

In order:
Ampulla 
Isthmus 
Fimbrial 
Interstitial (as tube enters uterus)

Question 5

Other than the Fallopian tubes, what other sites occur?

Answer 5

Ovary
Cervix
Peritoneum 
Scars of previous c section 
Myometrium

Question 6

What risk factors are there?

Answer 6

Anything that affects tubal function - infection, surgery, adhesions
Previous ectopic
PID
Endometriosis 
History of infertility or assisted conception 
Smoking 
IUD
POP

Question 7

What clinical features are associated?

Answer 7

Features may be subtle and non specific
Unilateral pain - RIF/LIF, lower abdominal, spreads to back
May be a generalised discomfort when lying down
Irregular PV spotting or bleeding - dark and sticky like prune juice
Amenorrhoea
Fainting, dizziness, collapse
Shoulder tip pain
Urinary discomfort
GI upset - diarrhoea, nausea and vomiting
All women of child bearing age presenting with any of above should have pregnancy test

Question 8

What signs are associated?

Answer 8

Abdominal/pelvic tenderness 
Rebound tenderness, peritonism
Abdominal distension 
Pallor
Cervical motion tenderness

Question 9

A ruptured ectopic pregnancy is a gynaecological emergency causing significant intra abdominal bleeding leading to…

Answer 9

Syncope
Haemodynamic instability
Vaginal bleeding may be present but often misleading regarding degree of blood loss as much will be intra abdominal

Question 10

How is it diagnosed?

Answer 10

Trans-vaginal USS = investigation of choice
Identifies majority of tubal ectopics on first assessment
A minority won’t be identified - termed pregnancy of unknown location (may be due to location or how early the scanning done)

Trans-abdominal only used if patient declines trans vaginal USS, but it has reduced sensitivity and specificity
MRI used second line - particularly useful in cervical scar or interstitial pregnancies
Serum beta HCG to help guide management

Question 11

Can a single serum B-HCG be used to predict an ectopic pregnancy?

Answer 11

No

A single low value does not exclude ectopic

Question 12

What are the 3 main types of management?

Answer 12

Expectant
Pharmacological
Surgical

Question 13

When should expectant management be considered?

Answer 13

Clinically stable and pain free
Unruptured tubal ectopic only, measuring less than 30mm with no visible heart beat on TVUS and
Serum beta hCG levels of 200 IU/L or less and
Able to return for follow up

Serum beta hCG measured at day 2,4,7 then weekly, levels should fall by 15% at each measurement - if they do not arrange a senior review

Question 14

Describe the pharmacological management

Answer 14

Single dose methotrexate IM - some may require subsequent doses if hCG has fallen by less than 15%
Serum beta hCG measured at day 4 and 7 then weekly
Methotrexate is teratogenic and mother should use reliable contraception for 3 months afterwards

Question 15

Who can be offered methotrexate?

Answer 15

No significant pain and
Unruptured tubal ectopic pregnancy, smaller than 35mm with no visible heartbeat and
Serum beta hCG less than 1500 IU/L and
Do not have an intrauterine pregnancy (confirmed on USS) and
Able to return for follow up

Question 16

Describe the surgical management

Answer 16

The laparoscopic approach should be used over open surgery when possible
In tubal ectopics, salpingectomy preferred to salpingotomy if the contralateral tube healthy

Question 17

When is emergency surgery indicated?

Answer 17

Ruptured ectopic

Question 18

What criteria indicate surgery?

Answer 18

Size >35mm
Can be ruptured
Severe pain
Visible fetal heartbeat
Serum B-hCG >1500IU 
Compatible with another intrauterine pregnancy

Question 19

What do those who have salpingotomy require?

Answer 19

Weekly serum beta hCG until negative

1 in 5 will need further treatment - methotrexate or salpingectomy

Question 20

When should anti D rhesus prophylaxis be given?

Answer 20

All women who have surgery to manage ectopic pregnancy

Question 21

Treatment with methotrexate is not appropriate if patient has what?

Answer 21

Severe anaemia 
Kidney or liver problems 
Ongoing infection 
HIV
Poetic ulcer or UC

Question 22

Why can referred shoulder tip pain occur?

Answer 22

Blood in the peritoneum irritates the diaphragm - sign of ruptured ectopic

Question 23

In a typical pregnancy, the serum hCG doubles…

Answer 23

Every 2 days

Question 24

When is a intra uterine pregnancy typically visible on trans vaginal USS?

Answer 24

Week 5 to 6

Question 25

Why can referred shoulder tip pain occur?

Answer 25

Blood in the peritoneum irritates the diaphragm - sign of ruptured ectopic

Question 26

In a typical pregnancy, the serum hCG doubles…

Answer 26

Every 2 days

Question 27

When is a intra uterine pregnancy typically visible on trans vaginal USS?

Answer 27

Week 5 to 6

Question 28

Are hCG levels predictive of rupture?

Answer 28

No

Question 29

What are the side effects of methotrexate?

Answer 29

Conjunctivitis
Stomatitis
Diarrhoea
Abdominal pain - if does not improve with simple analgesia, should go to hospital immediately