Ectopic pregnancy/PUL (pregnancy of unknown location)

Question 1

What is an ectopic pregnancy?

Answer 1

An ectopic pregnancy is when a pregnancy is implanted outside the uterus

Question 2

What is the most common site for an ectopic pregnancy?

Answer 2

The ampulla of the fallopian tube

Question 3

What are the other sites an ectopic pregnancy can implant?

Answer 3

• cornual region (entrance to fallopian tube)
• ovary
• cervix
• abdomen

Question 4

What risk factors can increase the chance of ectopic pregnancy?

Answer 4

• prev ectopic pregnancy
• prev PID
• prev surgery to fallopian tubes
• intrauterine devices
• older age
• smoking

Question 5

When does an ectopic pregnancy typically present with symptoms?

Answer 5

around 6-8 weeks gestation

Question 6

What are the classic symptoms and features of an ectopic pregnancy?

Answer 6

• missed period
• constant lower abdo pain in the right or left iliac fossa
• vaginal bleeding
• lower abdo or pelvic pain
• cervical motion tenderness (pain when moving cervix in bimanual exam)
• syncope/dizziness
• shoulder tip pain –> peritonitis

Question 7

What is the gold standard investigation for an ectopic pregnancy?

Answer 7

-transvaginal US –> a gestational sac containing yolk sack or foetal pole may be seen in a fallopian tube

Question 8

What is a mass containing an empty gestational sac referred to?

Answer 8

-blob sign/ bagel sign/ tubal ring sign

Question 9

How do you differentiate a tubal ectopic pregnancy mass from a corpus luteum?

Answer 9

tubal ectopic pregnancy moves seperate to the ovary while corpus luteum will move with the ovary

Question 10

What are features that may indicate ectopic pregnancy in an US scan?

Answer 10

• empty uterus

- fluid in uterus which may be mistaken as a gestational sac (pseudogestational sac)

Question 11

What is a pregnancy of unknown location PUL?

Answer 11

-when a woman has a positive pregnancy test and no evidence of pregnancy is seen on the US scan

Question 12

How does serum HCG differ in an intrauterine pregnancy and a miscarriage/ectopic pregnancy?

Answer 12

-In IU pregnancy the hcg will double every 48 hours while in ectopic/miscarriage it will not

Question 13

How is a PUL managed?

Answer 13

• after US scan confirms no evidence of pregnancy, hCG levels repeated after 48 hrs
• if they rise >63% this likely indicates and IU pregnancy and a repeat US scan is needed after 1-2 weeks (pregnancy should be visible on US when hcg>1500)
• if rise <63% this likely indicates ectopic pregnancy and pt needs close monitoring
• if they fall >50% this likely indicates miscarriage and urine pregnancy test should be performed 2 weeks after to confirm miscarriage is complete
• monitoring symptom changes is more important than hCG level

Question 14

What needs to be performed in all women presenting with abdo/pelvic pain that can be caused by ectopic pregnancy?

Answer 14

-pregnancy test

Question 15

If a women presenting with pelvic pain/tenderness has a positive pregnancy test what should you do?

Answer 15

-refer to early pregnancy unit/gynae service

Question 16

What is the general treatment for all ectopic pregnancies?

Answer 16

Termination of pregnancy

Question 17

What are the three options for terminating an ectopic pregnancy?

Answer 17

• Expectant management (awaiting natural termination)
• Medical management (methotrexate)
• surgery ( salpingectomy or salpingotomy)

Question 18

What is the criteria to be viable for expectant management in ectopic pregnancy?

Answer 18

• follow up needs to be possible to ensure successful termination
• needs to be unruptured
• adnexal mass < 35mm
• no visible heartbeat
• no significant pain/symptoms
• HCG level <1500 IU/L

Question 19

What should be closely monitored in expectant management?

Answer 19

• HCG levels

- symptom changes

Question 20

What is the criteria to be viable for medical management with methotrexate in ectopic?

Answer 20

• HCG level must be <5000 IU/l

- confirmed absence of IU pregnancy on US

Question 21

How is methotrexate given and how does it work to terminate pregnancy?

Answer 21

• given IM into buttock

- highly teratogenic and so halts progress of pregnancy and results in spontaneous miscarraige

Question 22

What advice should be given to women on methotrexate?

Answer 22

-advised to not get pregnant for 3 moths following treatment

Question 23

What are common side effects of methotrexate?

Answer 23

• vaginal bleeding
• nausea and vomiting
• abdo pain
• stomatitis

Question 24

What is the criteria to be viable for surgical management with methotrexate in ectopic?

Answer 24

• anyone who does not meet criteria for expectant and medical
• most ectopics are dealt with surgically
• pain
• adnexal mass > 35mm
• visible heartbeat
• Hcg levels > 5000 IU/l

Question 25

What are the two surgical options?

Answer 25

• laparoscopic salpingectomy (first line)

- laparoscopic salpingotomy

Question 26

What does laparoscopic salpingectomy involve?

Answer 26

-general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with ectopic pregnancy

Question 27

What does laparoscopic salpingotomy involve?

Answer 27

• used in women at increased of infertility due to damage to other tube
• aim to avoid removing affected fallopian tube and cut in to just remove the ectopic then close the cut

Question 28

What is risk of salpingotomy?

Answer 28

• increased risk of failure to remove ectopic compared to salpingectomy
• 1 in 5 women require futher treatment with methotrexate and salpingectomy after a salpingotomy

Question 29

What is given to rhesus negative women having surgical management of ectopic?

Answer 29

-anti-rhesus D prophylaxis (250IU); no Kleihauer test needed for surgical management of ectopic

Question 30

ectopic pregnancy summary

Answer 30

Question 31

A 22-year-old woman attends her general practitioner with a 1-week history of left sided pelvic pain.

On examination, there is mild tenderness in the left iliac fossa, with no peritonism or guarding. Her observations are normal.

Her last menstrual period was 4 weeks prior.

A urinary pregnancy test is positive, to her surprise.

She is referred to the early pregnancy assessment unit where a transvaginal ultrasound scan is performed. There is no pregnancy visible within the uterus, and there is no free fluid identified in the pelvis. A serum B-hCG is 315 mIU/mL.

She wishes to proceed with a termination of pregnancy.

What is the most appropriate management?

A. Methotrexate

B. Admit for an exploratory laparoscopy

C. Misoprostol

D. Repeat serum B-hCG in 48 hours.

E. Mifepristone

Answer 31

D. Repeat serum B-hCG in 48 hours.

This woman has a pregnancy of unknown location. As she is haemodynamically stable with mild pelvic pain, she can be managed conservatively.

Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.

1. If the levels fall (>50%) then it is suggested that the foetus will not develop or there has been a miscarriage.
2. If there is only a slight increase (rise of less than 63%) or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.
3. A large increase in B-hCG (rise of more than 63%) suggests the foetus is growing normally intrauterine. In this case a repeat transvaginal scan may be performed, and if the pregnancy is confirmed as intrauterine, the woman may proceed with termination of pregnancy.