ECTOPIC PREGNANCY Flashcards
Most frequent sites of tubal pregnancy
Ampulla
Risks of Ectopic Pregnancy
surgeries for a prior tubal pregnancy, for fertility restoration, or for sterilization – HIGHEST RISK
after one previous ectopic pregnancy - chance of another is ↑ fivefold
prior STD or other tubal infection
one episode of salpingitis - can be followed by a subsequent ectopic pregnancy in up to 9 % of women
peritubal adhesions subsequent to salpingitis, appendicitis, or endometriosis
congenital fallopian tube anomalies - secondary to in utero diethylstilbestrol exposure
ovulation induction and ART
smoking
atypical implantations - cornual, abdominal, cervical, ovarian, and heterotopic pregnancy
history of STIs or PID prior ectopic pregnancy previous tubal surgery prior pelvic or abdominal surgery resulting in adhesions endometriosis IVF or assisted reproductive techniques congenital fallopian tube anomalies (DES exposure in utero) smoking contraceptive method failure (IUD use)
Common in fimbrial and ampullary pregnancies
Abortion
Common in tubal isthmus
Rupture
Classic presentation of Ectopic Pregnancy
delayed menstruation
pain
vaginal bleeding or spotting
Reported by 60 to 80 % of women with tubal pregnancy
vaginal spotting or bleeding
Performed to look for findings indicative of intrauterine or ectopic pregnancy
Transvaginal sonography
Reliable diagnosis in most cases of suspected ectopic pregnancy
Laparoscopy
Methotrexate
Highly effective against rapidly proliferating tissue such as trophoblast, and overall ectopic tubal pregnancy
binds to dihydrofolate reductase
TOXIC to HEPATOCYTES
renally excreted
Used to counteract bone marrow depression d.t. MTX
Leucovorin
Predictors of MTX Treatment Failure
fetal cardiac activity
size and volume of gestational mass (> 4 cm)
high initial hCG concentration (> 5,000 mIU/mL)
hemoperitoneum
rapidly increasing hCG concentrations (> 50% over 48 hrs) before MTX treatment
continued rapid rising of hCG concentrations during MTX therapy
Criteria for Medical Management in Ectopic Pregnancy
stable patient β-hCG <1,500 mIU/mL size <3.5 cm AOG < 6 weeks no fetal heartrate/beat
The single best prognostic indicator of successful treatment with single-dose methotrexate
initial serum β-hCG level
The preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable
Laparoscopy
Defined by cervical glands noted histologically opposite the placental attachment site and by part or all of the placenta found below the entrance of the uterine vessels or below the peritoneal reflection on the anterior uterus
Cervical Pregnancy
Characteristic Clinical Findings in Cervical Pregnancy
uterine bleeding after amenorrhea w/o cramping pain
softened cervix that is disproportionally enlarged
complete confinement and firm attachment of the products of conception
closed internal OS
Rubin and Colleague’s Criteria (Cervical Pregnancy)
attachment of the placenta to the cervix must be intimate
cervical glands must be present opposite the placental attachment
placenta must be below the entrance of the uterine vessels or below the peritoneal reflection of the anteroposterior surface of the uterus
fetal elements must NOT be present in the corpus uteri
Secondary to tubal abortion with secondary implantation in the peritoneal cavity
Abdominal Pregnancy
Studdiford’s Criteria For Abdominal Pregnancy
fallopian tubes and ovaries must be normal (no evidence of recent or past injury)
no evidence of uteroplacental fistula
pregnancy must be related only to the peritoneal surface and early enough in gestation to eliminate the possibility of secondary implantation after primary tubal ligation
Clinical Criteria of Ovarian Pregnancy
ipsilateral tube is intact and distinct from the ovary
ectopic pregnancy occupies the ovary
ectopic pregnancy is connected by the uteroovarian ligament to the uterus
ovarian tissue can be demonstrated histologically amid the placental tissue
Spiegelburg’s Criteria For Ovarian Pregnancy
tube and fimbria must be intact and separate from the ovary
gestational sac must occupy the normal position of the ovary
the sac must be connected to the uterus by the ovarian ligament
ovarian tissue should be demonstrable in the walls of the sac
Contraceptive method failures with increased relative number of ectopic pregnancies
Tubal sterilization
Copper and Progestin releasing Intrauterine Devices (IUD)
Progestin Only Contraceptives
Outcomes of Ectopic Pregnancy
tubal rupture
tubal abortion
pregnancy failure with resolution
Classic presentation of ectopic pregnancy
delayed menstruation
pain
vaginal bleeding or spotting
Nongynecological sources of lower abdominal pain in early pregnancy
appendicitis
cystitis
renal stone
gastroenteritis
Key components in the algorithms for ectopic pregnancy
physical findings
transvaginal sonography
serum b-hCG level measurement
diagnostic surgery - uterine curettage, laparoscopy and laparotomy
Ruptured ectopic pregnancy
hypotension
tachycardia
signs of peritoneal irritation sec to hemoperitoneum
Endometrial Findings (Ectopic Pregnancy)
trilaminar endometrial pattern
anechoic fluid collections
pseudosac
decidual cyst
Direct visualization of the fallopian tubes and pelvis
Laparoscopy
Specific risk factor of INTERSTITIAL PREGNANCY
previous ipsilateral salpingectomy
Methotrexate Contraindications
sensitivity to MTX tubal rupture breastfeeding intrauterine pregnancy PUD active pulmonary disease immunodeficiency hepatic, renal or hematologic condition
