Ectopic Pregnancy

Question 1

What is an ectopic pregnancy?

Answer 1

A fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the Fallopian tube (esp. ampulla) (97%), followed by the ovary (3.2%) and the abdomen (1.3%). If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage.

Question 2

What are the key diagnostic features of ectopic pregnancy?

Answer 2

• abdominal pain
• amenorrhoea
• vaginal bleeding
• abdominal tenderness
• adnexal tenderness or mass
• blood in the vaginal vault
• haemodynamic instability, orthostatic hypotension
• cervical motion tenderness

OTHERS-
urge to defecate, referred shoulder pain

Question 3

What are the risk factors for ectopic pregnancy?

Answer 3

• previous ectopic pregnancy
• previous tubal sterilisation
• in utero diethylstibestrol exposure of the mother
• intrauterine device (IUD) use
• previous genital infection
• chronic salpingitis
• salpingitis isthmica nodosa
• infertility
• multiple sexual partners
• smoking
• assisted reproductive technology
• first sexual encounter <18
• maternal age >35
• tubal reconstruction surgery

Question 4

How many pregnancies are affected?

Answer 4

About 1/100

Question 5

How does ectopic pregnancy typically present?

Answer 5

• patients will usually present 6-8 weeks after their last period, however 30% present before a missed period.
• common symptoms are PV bleeding (dark or fresh- can occur with or without rupture) and/or abdominal/pelvic pain. Many patients are asymptomatic.

OTHER POSSIBLE FEATURES-

• syncope and dizziness
• shoulder tip pain
• painful defecation and urination
• diarrhoea and vomiting
• adnexal mass or big uterus
• cervical excitation
• sudden rupture->peritonism and shock

Question 6

What are the risk factors for ectopic (ecTOPIC)?

Answer 6

Tubal ligation or surgery
Ovulation induction
Past history of ectopic pregnancy
Inflammation eg. PID
Coil (IUCD) in situ

Question 7

How is ectopic pregnancy investigated?

Answer 7

• Urine Beta-HCG - positive
• Transvaginal ultrasound (TVUS) is the most sensitive test to confirm a viable intrauterine pregnancy or visualise an ectopic embryo. If neither can be seen in the presence of positive pregnancy test known as “pregnancy of unknown location”.
• abdominal US alternative to TVUS
• serum beta-HCG serial tests if no intrauterine pregnancy confirmed on imaging. Falling values suggest miscarriage, while slow rising values-<63% in 48 hours suggests ectopic and should be reviewed 24hours later.

Question 8

How is an ectopic pregnancy managed? (conservative, medical and surgical)

Answer 8

CONSERVATIVE

• if no acute symptoms, ectopic mass <3.5 cm, no metal heartbeat and B-HCG<1000 (consider at 1000-1500) and falling.
• Follow up and ensure adnexal mass shrinks and B-HCG drops.

MEDICAL

• Methotrexate IM
• Indications- as for conservative (mass size and no heartbeat) but with B-HCG up to 1500 (consider at 1500-5000).
• CONTRAINDICATIONS- if above indications not met (due to risk of rupture) plus usual methotrexate contraindications (cytopenia, peptic ulcer, liver disease)
• Side effects- abdominal pain

SURGICAL

• Indications- unstable, significant pain, methotrexate contraindicated
• Procedure- laparoscopic if possible, either salpingectomy (tube removal) or salpingotomy (dissecting the ectopic) if there is only one healthy tube remaining.
• Anti-D prophylaxis if rhesus negative and surgically managed.

Question 9

What are the complications of ectopic pregnancy?

Answer 9

Maternal mortality is around 1/5000 ectopic pregnancies.