Ectopic Pregnancy + Termination Flashcards
What is an ectopic pregnancy?
- occurs when a pregnancy is implanted outside of the uterus
- the fallopian tube is the most common site
it can also occur in the entrance to the tube (cornual region), ovary, cervix or abdomen
What are the risk factors for ectopic pregnancy?
- previous ectopic pregnancy
- previous PID
- older age
- smoking
- previous surgery to the fallopain tubes
- intrauterine devices (coils)
When does ectopic pregnancy tend to present?
around 6 - 8 weeks gestation
What questions should be asked to all patients to avoid missing ectopic pregnancy?
- possiblity of pregnancy
- date of last period
- any missed periods
- recent unprotected sex
these questions should be asked to any woman presenting with lower abdominal pain
What are the presenting features of an ectopic pregnancy?
- constant lower abdominal pain in the RIF / LIF
- missed period
- cervical motion tenderness
- lower abdominal / pelvic tenderness
- vaginal bleeding
cervical motion tenderness = pain when moving the cervix on bimanual examination
What other questions related to ectopic pregnancy must be asked?
- presence of dizziness / syncope can occur due to blood loss
- shoulder tip pain indicates peritonitis
What is the investigation of chioce for diagnosing ectopic pregnancy?
transvaginal USS
- a gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
What is meant by the “blob sign” on USS?
- the presence of a non-specific mass in the fallopian tube
- there is an empty gestational sac
this is also called “bagel sign”or “tubal ring sign”
How can a tubal ectopic pregnancy be differentiated from a corpus luteum?
- a mass representing an ectopic pregnancy moves separately to the ovary
- a corpus luteum will move WITH the ovary
What other features may be present on USS in an ectopic pregnancy?
- empty uterus
- pseudogestational sac (fluid in the uterus that can be mistaken for a gestational sac)
What is a pregnancy of unknown location (PUL)?
- occurs when there is a positive pregnancy test
AND
- no evidence of pregnancy on USS
ectopic pregnancy CANNOT be excluded and careful follow-up is required
What is monitored to follow-up a PUL?
serum human chorionic gonadotrophin (hCG)
- serum hCG level is repeated after 48 hours to measure the change from baseline
How does serum hCG level change over time in an intrauterine pregnancy?
- the developing syncytiotrophoblast produces hCG
- in an intrauterine pregnancy, hCG doubles every 48 hours
- this is NOT the case in miscarriage / ectopic pregnancy
How is serum hCG level used to determine whether an ectopic pregnancy / PUL is present?
- a rise of >63% after 48 hours is likely to indicate intrauterine pregnancy
- a repeat US is required after 1-2 weeks to confirm this
- a rise of < 63% after 48 hours may indicate ectopic pregnancy
- close monitoring / review is required
At what serum hCG level should a pregnancy be visible on US?
a pregnancy should be visible on US when hCG level is above 1500 IU/l
What change in hCG level is likely to indicate miscarriage?
- a fall in hCG of > 50% over 48 hours
- a urine pregnancy test is performed after 2 weeks to confirm the miscarriage is complete
What is the first line investigation for suspected ectopic pregnancy?
urine pregnancy test
- should be performed in all women with abdominal / pelvic pain
What is the aim of management of an ectopic pregnancy?
- all ectopic pregnancies need to be terminated
- ectopic pregnancies are not viable pregnancies
What are the 3 options for terminating an ectopic pregnancy?
- expectant management (await natural termination)
- medical management (methotrexate)
- surgical management (salpingectomy / salpingotomy)
What are the criteria required for expectant management?
- follow-up must be possible to ensure successful termination
- no significant pain
- no visible heartbeat
- hCG < 1500 IU/l
- adnexal mass < 35mm
- ectopic must be unruptured
What is the criteria for management with methotrexate?
- the same as the criteria for expectant management, except:
- hCG < 5000 IU/l
- confirmed absence of intrauterine pregnancy on USS
How is methotrexate administered and how does it work?
- given as an intramuscular injection into the buttock
- it is highly teratogenic
- it halts the process of pregnancy + results in spontaneous termination
What advice is given to women after methotrexate treatment?
- use protection / do NOT get pregnant for 3 months afterwards
- the teratogenic effects are long-lasting
What are the common side effects of methotrexate?
- vaginal bleeding
- N&V
- abdominal pain
- stomatitis (inflammation of the mouth)
What patients will require surgical management of their ectopic pregnancy?
- anyone with significant pain
- hCG > 5000 IU/l
- adnexal mass > 35mm
- visible heartbeat
What are the 2 options for surgical management of ectopic pregnancy?
- laparoscopic salpingectomy
- laparoscopic salpingotomy
What is involved in laparoscopic salpingectomy?
- the entire affected fallopian tube is removed
- the ectopic pregnancy is removed with the tube
- this is the FIRST-LINE treatment
What is involved in a laparoscopic salpingotomy?
Why might this be chosen?
- a cut is made in the fallopian tube, the ectopic pregnancy is removed and the tube is closed
- this aims to avoid removing the fallopian tube
- preferred in women at increased risk of infertility due to damage to the other tube
What is the major risk associated with salpingotomy?
- there is an increased risk of failure to remove the ectopic pregnancy tissue
- 1 in 5 women may need further treatment with methotrexate / salpingectomy
What additional medication may need to be given prior to surgery?
anti-D prophylaxis
- should be given to all Rhesus negative women prior to surgical management
What is the definition of a termination of pregnancy (TOP) / abortion?
an elective procedure to end a pregnancy
What is the maximum gestational age at which abortion can be performed?
it is legal to perform an abortion up to 24 weeks gestation
What are the criteria for abortion prior to 24 weeks gestation?
continuation of the pregnancy involves greater risk to the physical or mental health of the woman / existing children of the family
this decision is a matter of clinical judgement
What are the criteria for performing an abortion at ANY time during the pregnancy?
- continuing it will risk the life of the woman
- termination will prevent “grave permanent injury” to the physical / mental health of the woman
- there is substantial risk that the child would suffer physical / mental abnormalities
What is involved in a medical abortion?
- mifepristone
- misoprostol (taken 1-2 days later)
- this is used in early pregnancy, but can be used at any gestation
How does mifepristone work?
- it is an anti-progestogen
- it blocks the action of progesterone
- this halts the process of pregnancy + relaxes the cervix
How does misoprostol work?
- it is a prostaglandin analogue
- it binds to / activates prostaglandin receptors
- this softens the cervix + stimulates uterine contractions
How frequently are misoprostol doses needed?
- it is given 1-2 days after mifepristone
- additional doses are required (e.g. every 3 hours) from 10 weeks gestation until expulsion is achieved
When is anti-D needed in medical TOP?
given to all Rhesus negative women with a gestational age of 10 weeks or above
What is required prior to surgical TOP?
cervical priming
- misoprostol / mifepristone / osmotic dilators are given
- this softens / dilates the cervix
What are osmotic dilators?
- devices inserted into the cervix that gradually expand as they absorb fluid
- this opens the cervical canal
What are the 2 options for surgical abortion?
- cervical dilatation + suction of the uterine contents (up to 14 weeks)
- cervical dilatation + evacuation using forceps (14 - 24 weeks)
When is anti-D required prior to surgical abortion?
- Rhesus negative women having a surgical TOP should have anti-D prophylaxis
- it is considered in women < 10 weeks gestation
What information is given to women about symptoms following TOP?
intermittent vaginal bleeding +/- abdominal cramps is common for up to 2 weeks afterwards
How is successful TOP confirmed?
urine pregnancy test performed 3 weeks after the procedure to confirm it is complete
What are the complications associated with TOP?
- bleeding
- pain
- infection
- failure of the abortion
- damage the the cervix / uterus
