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AIP: Abdominal pain > Ectopic pregnancy > Flashcards

Ectopic pregnancy Flashcards

1
Q

What is an ectopic pregnancy?

A

pregnancy which is implanted at a site outside of the uterine cavity

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2
Q

What proportion of pregnancies in the UK are ectopic?

A

1 in 80-90 pregnancies

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3
Q

What are the 2 most common sites for ectopic pregnancies?

A

ampulla and isthmus of fallopian tube

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4
Q

What are 3 less common sites for implantation of ectopic pregnancies?

A
  1. Ovaries
  2. Cervix
  3. Peritoneal cavity
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5
Q

What are 8 risk factors for ectopic pregnancy?

A
  1. Previous ectopic pregnancy
  2. Pelvic inflammatory disease (due to adhesion formation)
  3. Endometriosis (adhesion formation)
  4. Intrauterine device or intrauterine system
  5. Progesterone oral contraceptive or implant (fallopian tube ciliary dysmotility)
  6. Tubal ligation or occlusion
  7. Pelvic surgery - especially tubal (e.g. reversal of sterilisation)
  8. Assisted reproduction i.e. embryo transfer in IVF
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6
Q

How can progesterone oral contraceptives or implants increase the risk of ectopic pregnancy?

A

Fallopian tube ciliary dysmotility

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7
Q

What is important to remember about the link between contraception and the risk of ectopic pregnancy?

A

Contraception actually reduces rate of pregnancy but if there is failure of contraception, pregnancy is more likely to be ectopic

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8
Q

What is the leading symptom of ectopic pregnancy?

A

Pain - lower/abdominal pain

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9
Q

What are 5 possible symptoms of ectopic pregnancy?

A
  1. Lower abdominal/pelvic pain
  2. Vaginal bleeding
  3. History of amenorhoea
  4. Shoulder tip pain
  5. Vaginal discharge
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10
Q

What causes vaginal bleeding in ectopic pregnancy?

A

Decidual breakdown in the uterine cavity due to suboptimal beta-hCG levels

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11
Q

Where does bleeding from ruptured ectopic pregnancy typically occur?

A

Intra-abdominal rather than vaginal - so PV bleeding doesn’t necessarily indicate a rupture

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12
Q

Why can ectopic pregnancy cause shoulder tip pain?

A

irritation of diaphragm by blood in the peritoneal cavity

because diaphragm and supraclavicular nerves (which innervate shoulder tip) share the C3-C5 dermatomes

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13
Q

What is the nature of vaginal discharge that may be present in ectopic pregnancy? What causes it?

A

brown in colour, classically described as being akin to prune juice

Result of the decidua breaking down

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14
Q

What might be present on examination in ectopic pregnancy? 4 things

A
  1. Abdominal tenderness
  2. Vaginal examination - cervical excitation
  3. Adnexal tenderness
  4. Haemodynamically unstable - if ruptured
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15
Q

What are 6 possible signs of haemodynamic instability on examination if an ectopic pregnancy has ruptured?

A
  1. Pallor
  2. Increased capillary refill time
  3. Tachycardia
  4. Hypotension
  5. Signs of peritonitis - abdominal rebound tenderness, guarding
  6. Fullness in pouch of Douglas (rectouterine pouch) on vaginal examination
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16
Q

When must you always consider ectopic pregnancy as a differential to rule out?

A

should always be considered in cases of abdominal pain in a woman of reproductive age

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17
Q

What are 6 differentials for ectopic pregnancy?

A
  1. Miscarriage
  2. Ovarian cyst accident (cyst haemorrhage, torsion or rupture)
  3. Acute pelvic inflammatory disease
  4. Urinary tract infection
  5. Appendicitis
  6. Diverticulitis
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18
Q

What are the first 2 initial investigations to perform in suspected ectopic pregnancy?

A
  1. Pregnancy test: beta-hCG: most important initial investigation
  2. If positive: pelvic USS
    • first abdominal, if pregnancy not seen →transvaginal
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19
Q

What is the role of the pelvic USS to investigate potential ectopic pregnancy?

A

determine presence or absence of intrauterine (‘normal’) pregnancy

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20
Q

What is the term given to the situation when pregnancy cannot be identified on ultrasound scan but beta-hCG is positive?

A

Pregnancy of unknown location

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21
Q

What are the 3 main differential diagnoses for a pregnancy of unknown location?

A
  1. Very early intrauterine pregnancy
  2. Miscarriage
  3. Ectopic pregnancy
22
Q

What should the next investigation be if pelvic ultrasound shows pregnancy of unknown location?

A

serum beta-hCG should be taken

23
Q

How is the serum beta-hCG used to determine management of potential pregnancy?

A
  • if initial beta-hCG >1500iU and no intrauterine pregnancy on transvaginal USS: consider ectopic pregnancy until proven otherwise
    • offer diagnostic laparoscopy
  • if initial beta-hCG <1500iU and patient stable:
    • take further blood test 48h later
    • if viable pregnancy, expect to double every 48 hours
    • in miscarriage, would halve every 48 hours
    • if change in beta-hCG outside these limits, ectopic pregnancy cannot be excluded, patient should be managed accordingly
24
Q

What are the 3 possible results of repeating serum beta-hCG 48 hours later if initial result is <1500iU?

A
  • in viable pregnancy, hCG would be expected to double every 48 hours
  • in miscarriage, hCG would halve every 48 hours
  • if increase or drop in rate of change outside these limits, ectopic pregnancy cannot be excluded - manage accordingly
25
Q

In addition to urine beta-hCG, pelvic USS and serum beta-hCG, what other investigations might you perform in suspected ectopic pregnancy?

A

Investigations as appropriate to rule in/our the other differential diagnoses e.g. urinalysis for UTI

26
Q

What are 5 elements of management of ectopic pregnancy?

A
  1. Admit to hospital
  2. If unstable, A-E approach to resuscitate
  3. Medical
  4. Surgical
  5. Conservative
27
Q

What may be required to stabilise a patient with a suspected ectopic pregnancy who is unstable?

A

Blood products if signs of haemodynamic instability

28
Q

What is the medical management of ectopic pregnancy?

A

IM methotrexate

29
Q

How does IM methotrexate work to manage ectopic pregnancy?

A

anti-folate cytotoxic agent that disrupts the folate-dependent cell division of the developing fetus

Pregnancy will then gradually resolve

30
Q

What monitoring must be performed alongisde the medical management of ectopic pregnancy? What is done as a result of this?

A

serum beta-hCG to ensure level is declining by >15% in day 4-5

if no decline, repeat dose administered

31
Q

What are 6 criteria for the medical management of ectopic pregnancy to be performed?

A
  1. Stable
  2. Well-controlled pain
  3. beta-hCG levels <1500 iU/ml
  4. Unruptured ectopic
  5. No visible heartbeat
  6. Patient must have access to 24-hour gynaecology services and informed of symptoms of rupture
32
Q

What are 2 key advantages of medical management of ectopic pregnancy?

A
  1. Avoids complications of surgical management
  2. Patient can be at home after the injection
33
Q

What are 6 disadvantages of methotrexate IM/the medical management of ectopic pregnancy?

A

Side effects of methotrexate

  1. Abdominal pain
  2. Bone marrow suppression
  3. Renal dysfunction
  4. Hepatitis
  5. Teratogenesis - must use contraception 3-6 months after methotrexate use
  6. Treatment can fail which would necessitate surgical intervention
34
Q

What is done due to the teratogenicity of methotrexate when treating ectopic pregnancy?

A

Inform patient that contraception must be used for 3-6 months afterwards

35
Q

What is the basis of surgical management of ectopic pregnancy?

A

removal of ectopic pregnancy

36
Q

What is the common management of tubal ectopics, and when is this contraindicated?

A
  • Laparoscopic salpingectomy - removing ectopic and tube it is implanted in
  • If damage to contralateral tube from infection, disease or surgery: salpingotomy - cut in fallopian tube to remove ectopic, and salvage tube to preserve fertility
37
Q

What further management must follow salpingotomy when this is used to manage ectopic pregnancy?

A

hCG follow up required until level reaches <5iu (negative), to ensure no residual trophoblast

38
Q

What is the risk of recurrent ectopic pregnancy in a salvaged tube after salpinogotomy vs salpingectomy?

A

increased risk of recurrence after salpingotomy

39
Q

What are 4 indications for surgical management of ectopic pregnancy?

A
  1. Severe pain
  2. Serum beta-hCG >5000iU/ml
  3. Adnexal mass >34mm
  4. Fetal heartbeat visible on scan
40
Q

What are the advantages of surgical management of ectopic pregnancy?

A

reassurance about when definitive treatment can be provided, high success rate

41
Q

What are 6 disadvantages of surgical management of ectopic pregnancy?

A
  1. General anaesthetic risk
  2. Risk of damage to neighbouring structures: bladder, bowel, ureters
  3. DVT/PE risk
  4. Haemorrhage risk
  5. Infection risk
  6. Risk of treatment failure with salpingotomy - some pregnancy may remain in tube
42
Q

What is conservative management of ectopic pregnancy?

A

watchful waiting of the stable patient, while allowing ectopic to resolve naturally . Serum beta-hCG must be monitored every 48 hours to ensure falling by 50%

43
Q

What steps must be taken before choosing conservative management of ectopic pregnancy?

A
  • not first line maangement- used in small number of selected patients only
  • needs to be discussed at senior level first
44
Q

What monitoring must be performed alongside watchful waiting for ectopic pregnancy?

A

serum-beta hCG monitored every 48 hours to ensure falling by equal to or greater than 50% of the level until it falls to approximately <5IU/ml

45
Q

What are 5 conditions that must be met for conservative management of ectopic pregnancy to be performed

A
  1. Stable patients - rupture unlikely
  2. Well-controlled pain
  3. Low baseline beta-hCG
  4. Small unruptured ectopic on USS
  5. Patient must have access to 24-hour gynaecology services and informed of symptoms of rupture
46
Q

What are 2 advantages of the conservative approach to ectopic pregnancy?

A
  1. Avoid risks of medical and surgical management
  2. Can be done at home
47
Q

What are the disadvantages of conservative management of ectopic pregnancy?

A

failure or complications necessitating medical or surgical management (25% of patients), rupture of ectopic

48
Q

What proportion of patients experience failure or complications necessitating medical or surgical treatment, following conservative management of ectopic pregnancy?

A

25%

49
Q

What can be the outcome of ectopic pregnancy rupture?

A

untreated ectopic pregnancy can lead to fallopian tube rupture - resulting blood loss can cause hypovolaemic shock, resulting in organ failure and death

50
Q

What type of ultrasound is best for diagnosing ectopic pregnancy?

A

transvaginal ultrasound

AIP: Abdominal pain (20 decks)

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