Ectopic pregnancy

Question 1

Pathophysiology?

Answer 1

Implantation of a fertilised ovum outside of the uterus

Question 2

Where is the most common location for this?

Answer 2

97% are tubal, with most in the ampulla

Question 3

What are the possible natural histories of this condition?

Answer 3

• Tubal abortion
• Tubal absorption (embryo and blood may be shed or converted into a tubal mole and absorbed)
• Tubal rupture

Most common are tubal absorption and tubal abortion

Question 4

Risk factors?

Answer 4

Anything that slows the ovum’s passage to the uterus:

• damage to tubes (pelvic inflammatory disease, surgery)
• previous ectopic
• endometriosis
• Intra-uterine contraceptive device (IUCD)
• progesterone only pill
• IVF (3% of pregnancies are ectopic)

Question 5

Symptoms?

Answer 5

• lower abdominal pain
  o due to tubal spasm
  o typically the first symptom
  o pain is usually constant and may be unilateral.
• vaginal bleeding
  o usually less than a normal period
  o may be dark brown in colour
• history of recent amenorrhoea
  o typically 6-8 weeks from the start of last period
  o if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
• peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
• dizziness, fainting or syncope may be seen
• symptoms of pregnancy such as breast tenderness may also be reported

Question 6

Examination findings?

Answer 6

• Abdominal tenderness
• Cervical excitation (also known as cervical motion tenderness)
• Adnexal mass

Question 7

What blood investigation can point towards a diagnosis of ectopic pregnancy?

Answer 7

Serum bHCG levels >1,500

Question 8

Where are patients managed depending on the severity of their symptoms?

Answer 8

Women who are stable are typically investigated and managed in an early pregnancy assessment unit.
If a woman is unstable then she should be referred to the emergency department.

Question 9

What investigations can be performed?

Answer 9

• Pregnancy test
• Transvaginal ultrasound (investigation of choice)
• serum bHCG

Question 10

When would you perform expectant management? What would that entail?

Answer 10

• Size <35mm
• Unruptured
• Asymptomatic
• No fetal heartbeat
• serum B-hCG <1,000 IU/L
• Compatible if there another intrauterine pregnancy

Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.

Question 11

When would you perform medical management? What would that entail?

Answer 11

• Size <35mm
• Unruptured
• No significant pain
• No fetal heartbeat
• serum B-hCG <1,500 IU/L
• Not suitable if intrauterine pregnancy

Medical management involves giving the patient methotrexate and can only be done if the patient is willing to attend follow up.

Question 12

When would you perform surgical management? What would that entail?

Answer 12

• Size >35mm
• Can be ruptured
• Pain
• Visible fetal heartbeat
• serum B-hCG >1,500 IU/L
• Compatible with another intrauterine pregnancy

Surgical management can involve salpingectomy or salpingotomy

Question 13

What is a heterotopic pregnancy?

Answer 13

A rare complication of pregnancy in which both extra-uterine (ectopic pregnancy) and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.