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Y4 - GOSH > Ectopic Pregnancy + Termination > Flashcards

Ectopic Pregnancy + Termination Flashcards

1
Q

What is an ectopic pregnancy?

A
  • 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

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2
Q

What are the risk factors for ectopic pregnancy?

A
  • previous ectopic pregnancy
  • previous PID
  • older age
  • smoking
  • previous surgery to the fallopain tubes
  • intrauterine devices (coils)
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3
Q

When does ectopic pregnancy tend to present?

A

around 6 - 8 weeks gestation

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4
Q

What questions should be asked to all patients to avoid missing ectopic pregnancy?

A
  • 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

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5
Q

What are the presenting features of an ectopic pregnancy?

A
  • 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

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6
Q

What other questions related to ectopic pregnancy must be asked?

A
  • presence of dizziness / syncope can occur due to blood loss
  • shoulder tip pain indicates peritonitis
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7
Q

What is the investigation of chioce for diagnosing ectopic pregnancy?

A

transvaginal USS

  • a gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube
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8
Q

What is meant by the “blob sign” on USS?

A
  • 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”

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9
Q

How can a tubal ectopic pregnancy be differentiated from a corpus luteum?

A
  • a mass representing an ectopic pregnancy moves separately to the ovary
  • a corpus luteum will move WITH the ovary
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10
Q

What other features may be present on USS in an ectopic pregnancy?

A
  • empty uterus
  • pseudogestational sac (fluid in the uterus that can be mistaken for a gestational sac)
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11
Q

What is a pregnancy of unknown location (PUL)?

A
  • 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

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12
Q

What is monitored to follow-up a PUL?

A

serum human chorionic gonadotrophin (hCG)

  • serum hCG level is repeated after 48 hours to measure the change from baseline
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13
Q

How does serum hCG level change over time in an intrauterine pregnancy?

A
  • the developing syncytiotrophoblast produces hCG
  • in an intrauterine pregnancy, hCG doubles every 48 hours
  • this is NOT the case in miscarriage / ectopic pregnancy
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14
Q

How is serum hCG level used to determine whether an ectopic pregnancy / PUL is present?

A
  • 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
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15
Q

At what serum hCG level should a pregnancy be visible on US?

A

a pregnancy should be visible on US when hCG level is above 1500 IU/l

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16
Q

What change in hCG level is likely to indicate miscarriage?

A
  • a fall in hCG of > 50% over 48 hours
  • a urine pregnancy test is performed after 2 weeks to confirm the miscarriage is complete
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17
Q

What is the first line investigation for suspected ectopic pregnancy?

A

urine pregnancy test

  • should be performed in all women with abdominal / pelvic pain
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18
Q

What is the aim of management of an ectopic pregnancy?

A
  • all ectopic pregnancies need to be terminated
  • ectopic pregnancies are not viable pregnancies
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19
Q

What are the 3 options for terminating an ectopic pregnancy?

A
  • expectant management (await natural termination)
  • medical management (methotrexate)
  • surgical management (salpingectomy / salpingotomy)
20
Q

What are the criteria required for expectant management?

A
  • 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
21
Q

What is the criteria for management with methotrexate?

A
  • the same as the criteria for expectant management, except:
  • hCG < 5000 IU/l
  • confirmed absence of intrauterine pregnancy on USS
22
Q

How is methotrexate administered and how does it work?

A
  • given as an intramuscular injection into the buttock
  • it is highly teratogenic
  • it halts the process of pregnancy + results in spontaneous termination
23
Q

What advice is given to women after methotrexate treatment?

A
  • use protection / do NOT get pregnant for 3 months afterwards
  • the teratogenic effects are long-lasting
24
Q

What are the common side effects of methotrexate?

A
  • vaginal bleeding
  • N&V
  • abdominal pain
  • stomatitis (inflammation of the mouth)
25
Q

What patients will require surgical management of their ectopic pregnancy?

A
  • anyone with significant pain
  • hCG > 5000 IU/l
  • adnexal mass > 35mm
  • visible heartbeat
26
Q

What are the 2 options for surgical management of ectopic pregnancy?

A
  • laparoscopic salpingectomy
  • laparoscopic salpingotomy
27
Q

What is involved in laparoscopic salpingectomy?

A
  • the entire affected fallopian tube is removed
  • the ectopic pregnancy is removed with the tube
  • this is the FIRST-LINE treatment
28
Q

What is involved in a laparoscopic salpingotomy?

Why might this be chosen?

A
  • 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
29
Q

What is the major risk associated with salpingotomy?

A
  • there is an increased risk of failure to remove the ectopic pregnancy tissue
  • 1 in 5 women may need further treatment with methotrexate / salpingectomy
30
Q

What additional medication may need to be given prior to surgery?

A

anti-D prophylaxis

  • should be given to all Rhesus negative women prior to surgical management
31
Q

What is the definition of a termination of pregnancy (TOP) / abortion?

A

an elective procedure to end a pregnancy

32
Q

What is the maximum gestational age at which abortion can be performed?

A

it is legal to perform an abortion up to 24 weeks gestation

33
Q

What are the criteria for abortion prior to 24 weeks gestation?

A

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

34
Q

What are the criteria for performing an abortion at ANY time during the pregnancy?

A
  • 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
35
Q

What is involved in a medical abortion?

A
  • mifepristone
  • misoprostol (taken 1-2 days later)
  • this is used in early pregnancy, but can be used at any gestation
36
Q

How does mifepristone work?

A
  • it is an anti-progestogen
  • it blocks the action of progesterone
  • this halts the process of pregnancy + relaxes the cervix
37
Q

How does misoprostol work?

A
  • it is a prostaglandin analogue
  • it binds to / activates prostaglandin receptors
  • this softens the cervix + stimulates uterine contractions
38
Q

How frequently are misoprostol doses needed?

A
  • 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
39
Q

When is anti-D needed in medical TOP?

A

given to all Rhesus negative women with a gestational age of 10 weeks or above

40
Q

What is required prior to surgical TOP?

A

cervical priming

  • misoprostol / mifepristone / osmotic dilators are given
  • this softens / dilates the cervix
41
Q

What are osmotic dilators?

A
  • devices inserted into the cervix that gradually expand as they absorb fluid
  • this opens the cervical canal
42
Q

What are the 2 options for surgical abortion?

A
  • cervical dilatation + suction of the uterine contents (up to 14 weeks)
  • cervical dilatation + evacuation using forceps (14 - 24 weeks)
43
Q

When is anti-D required prior to surgical abortion?

A
  • Rhesus negative women having a surgical TOP should have anti-D prophylaxis
  • it is considered in women < 10 weeks gestation
44
Q

What information is given to women about symptoms following TOP?

A

intermittent vaginal bleeding +/- abdominal cramps is common for up to 2 weeks afterwards

45
Q

How is successful TOP confirmed?

A

urine pregnancy test performed 3 weeks after the procedure to confirm it is complete

46
Q

What are the complications associated with TOP?

A
  • bleeding
  • pain
  • infection
  • failure of the abortion
  • damage the the cervix / uterus

Y4 - GOSH (62 decks)

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