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)
