Ectopic pregnancy + GTD Flashcards
What is ectopic pregnancy?
Any pregnancy which is implanted at a site outside the uterine cavity. Most common sites are the ampulla and isthmus of the Fallopian tube, less commonly ovaries, cervix or peritoneal cavity can be involved.
Risk factors of ectopic pregnancy?
PMH: Previous ectopic pregnancy, PID (adhesion formation), endometriosis (adhesion formation)
Contraception: IUD, IUS, POCP/implant (due to Fallopian tube ciliary dysmotility). Tubal ligation/occlusion. (reduces rate of pregnancy but if method fails pregnancy could be ectopic)/
Iatrogenic: Pelvic surgery (tubal), assisted reproduction (embryo transfer in IVF).
Clinical features of ectopic pregnancy?
1) PAIN - lower abdominal/pelvis +/- vaginal bleeding.
2) Amennorhoea
3) Shoulder tip (due to diaphragmatic irritation by blood in peritoneal cavity (C3,4,5 shared by diaphragm and supraclavicular nerves)
4) Vaginal discharge - brown colour - prune juice due to decidua breakdown.
O/E: local abdominal tenderness, cervical excitation and/or adnexal tenderness.
Ectopic pregnancy CAN RUPTURE.
3 signs of ectopic pregnancy rupture?
1) HAEMODYNAMICALLY UNSTABLE (pallor, tachycardia, tachycardiapnoea, hypotension, PCRT)
2) Signs of peritonitis (rebound tenderness and guarding in abdomen)
3) Fullness in pouch of Douglas.
Ddx of ectopic pregnancy?
ALWAYS consider in abdominal pain in women of reproductive age.
1) Miscarriage
2) Ovarian cyst accident
3) Acute PID
4) UTI
5) Appendicitis
6) Diverticulitis
Investigation of ectopic pregnancy?
1) PREGNANCY TEST - urine B-hCG
2) If positive order pelvic ultrasound - determine whether pregnancy intrauterine or ectopic, if not intrauterine transvaginal should be offered,
3) If pregnancy cannot be seen on transvaginal ultrasound - PREGNANCY OF UNKNOWN LOCATION (very early intrauterine pregnancy, miscarriage or ectopic) and SERUM B-HCG taken.
4) Initial B-HCG is >1500 iU (discriminatory level) and NO intrauterine pregnancy on transvaginal US - Ectopic until proven otherwise - diagnostic laproscopy offered.
- Initial B-HCG <1500 iU and patient is stable, further blood test taken 48 hours later - in viable pregnancy HCG doubles every 48hours, in miscarriage it halves every 48 hours. Increase or drop outside these limits - ectopic pregnancy cannot be excluded - managed accordingly.
- ABCDE might be required in unstable patients to resuscitate - untreated can lead to Fallopian tube rupture - resulting blood loss can result in shock - organ failure/death.
Medical management of ectopic pregnancy?
Medical: IM Methotrexate - disrupts folate dependant cell division of the developing fetus. Pregnancy will gradually resolve - monitor serum B-HCG regularly, repeat dose if no decline in HCG.
Medical management to stable patients - well-controlled pain and B-HCG levels <1500 iU/ml, unruptured ectopic, without visible heart beat. 24 hr gynaecology access and informed about rupture symptoms.
Advantages - no surgical complications - sent home after injection.
Disadvantages - side effects of methotrexate - abdominal pain, myelosuppression, renal dysfunction, hepatitis, teratogenesis (TAKE CONTRACEPTION FOR 3-6 MONTHS AFTER USE OF METHOTREXATE). Treatment can fail - would need surgical intervention.
Surgical management of ectopic pregnancy?
Tubal ectopics - laparoscopic SALPINGECTOMY (removing ectopic and tube it is implanted in.
- If other tube is damaged from infection/disease/surgery, do salpingotomy (cut in Fallopian tube removing ectopic) to preserve fertility.
- HCG followed up is required until <5iU (negative) to ensure no residual trophoblast which increases risk of recurrent ectopic in savaged tube.
Surgical management to patients with severe pain, serum B-HCG >5000, adnexal ass .34mm and/orfetal heartbeat visible on scan.
Advantages: Reassurance about when definitive treatment can be provided - high success rate.
Disadvantages: Anaesthetic risk, surgical risk - bladder, bowel, ureters, DVT/PE, haemorrhage infection. His of failure with Sapingotomy.
ALL RHESUS NEGATIVE WOMEN WITH SURGICAL MANAGEMENT - ANTI-D PROPHYLAXIS.
Conservative management of ectopic pregnancy?
- Watchful waiting of the stable patient - allowing the ectopic to resolve naturally - only suitable in small number of patients and is not first line.
- Serum B-HCG monitored every 48 hours to ensure it is falling by 50% or more until it falls to approximately 5mlIU/ml.
- Offered where - rupture unlikely, stable, well controlled pain, low baseline B-HCG, small enraptured ectopic on USS.
- 24 hour access to gynae and informed of rupture symptoms.
Advantages - avoid risks of medical and surgical management and done at home.
Disadvantages - failure or complications necessitating medical/surgical management , and rupture.
What is gestational trophoblastic disease (GTD)?
- Group of pregnancy related tumours: divided into pre-malignant and malignant conditions.
Pre-malignant (more common) - partial molar pregnancy and complete molar pregnancy.
Malignant (rarer) - invasive mole, choriocarcinoma, placental trophoblastic site tumour, epithelioid trophoblastic tumour.
PPx of GTD (Molar pregnancies)?
- In normal conception the foetus is formed from 23 maternal chromosomes and 23 paternal chromosomes - molar pregnancy arises from the abnormality in chromosomal number during fertilisation.
- Partial molar pregnancy - where one ovum with 23 chromosomes is fertilised by 2 sperm (each with 23c) - so this produces cells with 69 chromosomes (triplody).
- Complete molar pregnancy occurs where one ovum without any chromosomes is fertilised by one sperm which duplicates (or less commonly 2 sperm), this leads to 46 chromosomes of paternal origin alone.
These tumours are usually benign but can become malignant - invading into the uterine myometrium and disseminating around the body - INVASIVE MOLES.
Other types of gestational trophoblastic disease?
- Choriocarcinoma - tumours of the trophoblastic placental cells - commonly but not exclusively, co-exists with a molar pregnancy. (characteristically metastasises to the lungs).
- Placental site trophoblastic tumour - a malignancy of the intermediate trophoblasts - normally responsible for anchoring the placenta to the uterus. (can occur after normal pregnancy, molar pregnancy or a miscarriage).
- Epithelioid trophoblastic tumour - malignancy of the trophoblastic placental cells, which can be very difficult to distinguish from choriocarcinoma. Mimics cytological features of squamous cell carcinoma.
Risk factors for GTD?
- Maternal age <20 or >35
- Previous gestational trophoblastic disease
- Previous miscarriage
- Oral contraceptive pill
Clinical features of GTD?
1) Molar pregnancies commonly present with vaginal bleeding and abdominal pain early in pregnancy.
2) ENLARGED uterus (bigger than expected in gestation) with a soft, boggy consistency.
3) Molar vesicles can shed via vagina.
- Diagnosis by ultrasound, if undiagnosed later symptoms can present (and a large for dates uterus):
1) Hyperemesis
2) Hyperthyroidism
3) Anaemia
Diagnosis of GTD?
1) Urine B-HCG
2) Blood B-HCG (elevated at diagnosis)
3) Ultrasound scan (complete mole has a granular/snowstorm appearance with central heterogenous mass and surrounding multiple cystic areas/vesicles.
4) Histological examination of the POC - performed post-treatment on molar pregnancies and all non-viable diagnosis to confirm diagnosis - if partial mole suspected and foetus is viable - if parents opt to continue pregnancy, placental histology should be performed after deliver.
If metastatic spread suspected - staging investigations include MRI, CT chest-abdomen-pelvis and/or pelvic ultrasound.
