Ectopic pregnancy – types. Tubal pregnancy – causes, symptoms, differential diagnosis, management.

Question 1

what is an ectopic pregnancy

Answer 1

Implantation of the embryo outside of the uterus. Occurs in 2% of pregnancies most common pregnancy related cause of death in 1 st trimester

Question 2

how does ectopic pregnancy happen

Answer 2

after ovulation the fertilized egg implants somewhere other than endometrium of the uterine cavity implant on a surface w/ adequate blood supply to support a developing embryo.

Question 3

what determines the development of the embryo in an ectopic pregnancy

Answer 3

the blood supply of the implanted area

Question 4

what happens if the area is poorly supplied in ectopic pregnancy

Answer 4

Tissue cannot provide a sufficient blood supply to support an embryo ==> DEATH

Question 5

rich blood suply of ectopic area

Answer 5

embryo can develop like a normal pregnancy hormones are released and Pregnancy related signs will begin to appear embryo will develop and grow – however the expansion will begin to Compress surrounding nerves & tissues

Question 6

consequences of ectopic embryo expansion

Answer 6

nerve pain crom compression or Rupture and hemrg

==>blood irritates peritoneum==>referred shoulder pain ( d/2 diagphragmatic irritation) and vaginal bleeding

 Internal bleeding => Severe pain!! medical emergency!

 Damage to fallopian tubes

Question 7

which consequences of ectopic embryo expansion are medical emergencies

Answer 7

Internal bleeding Severe pain Damage to fallopian tube

Question 8

risk factors of ectopic pregnancies

Answer 8

• Smoking reduces uterine bf
• History of PID==> adhesions Inflammation + scarring of intra and extra luminal structures which impair normal tubal function and fosters implantation into the tube.
• Gynae surgery e.g tubal surgery ==>leads to scarring and narrowing of the tube (outflow tract obstructions)
• History of ectopic pregnancy
• Abnormal function of fallopian tubes –usually the tubes facilitate the collection and transport of the oocyte and embryo into the uterus- Retarded migration of the fertilized ovum ^ risk of implantation
• Artificial reproductive techniques – retrograde embryo migration

Question 9

what does the clinical presentation depend on in ectopic pregnancy

Answer 9

1. The location of the ectopic pregnancy 2. Symptomatic / asymptomatic 3. Rupture

Question 10

clinical symptoms of ectopic pregnancy

Answer 10

usually asymptomatic

Amenorhea is primary sx as it mimics preg

Vaginal bleeding – 7-14 days post period because of lack of implantation in the uterus so membrane sheds?

Abdominal pain and onesided pelvic pain

Pregnancy test shows – elevated hcg- mimics preg -if HCG levels are low then this suggests dx from early miscarriageas sim sx if amenorrhea and bleeding

Question 11

what determines the physical exam in ectopic pregnancy

Answer 11

whethere there is rupture or not

Question 12

presentation of ruptured ectopic pregnancy

Answer 12

• tachycardia
• hypovolemic shock signs
  
  • hypotension, cold skin, etc
• acute abdomen d/2 haemoperitoneum
  
  • distention -guarding -rebound tenderness -cervical motion tenderness (chandelier sign)

Question 13

physical exam in abscence of rupture

Answer 13

normal

Question 14

dg for ectopic pregnancy

Answer 14

1. B HCG: normal lvs Rapidly increased suring the 1st trimester of pregnancynand doubles every 2 days if pregnancy is viable until 12 wks
2. US : check for presence of gestational sac by 6th week once hcg is at discriminative zone
3. D&C: check for chorionic villi
4. serum progesterone: should be over 25 ng/l if viable
5. laparoscopy: confirmatory dg

Question 15

how B HCG os used in ectopic pregnancy

Answer 15

Rapidly increased suring the 1st trimester of pregnancy doubles every 2 days if pregnancy is viable

Question 16

US in ectopic pregnancy

Answer 16

viable intrauterine pregnancies can be visualized by transvaginal ultrasound at a gestational age greater than 5.5 to 6 weeks lack of intrauterine preg suggests ectopic presence of intrauterine excludes ectopic

Question 17

what is the discriminative zone

Answer 17

amount of b hcg above which intrauterine pregnancies should be visualised by US

Question 18

what does it mean if thb hcg is above the discriminative zone but not seen on US

Answer 18

non viable preg

Question 19

what does it mean If the quantitative hCG is below the discriminatory zone + ultrasound is nondiagnostic

Answer 19

follow serial quantitative hCG levels to distinguish a viable intrauterine pregnancy from a nonviable gestation

Question 20

If hCG levels ^ above discriminatory zone

Answer 20

repeat US to confirm pregnancy

Question 21

when & why is DC done in ectopic preg

Answer 21

• to look for Chorionic Villi
• when intrauterine not detected in US when hcg level is higher the discrimnatory zone

Question 22

what does an abscence of chorionic villi in DC show when hcg is at discriminative zone

Answer 22

ectopic pregnancy

Question 23

serum progesterone lvls in ectopic pregnancy

Answer 23

used as adjuct as they;re controvesial

Question 24

lvl of progesterone in non viable pregnancies

Answer 24

less than 5ng/mL

Question 25

lvl of progesterone in viable intrauterine pregnancies

Answer 25

25ng/mL

Question 26

when is laparoscopy used in ectopic pregnancy

Answer 26

if doubt persists after the other methods of dg

Question 27

what determines rx of ectopic

Answer 27

assx/ symps

ruptured or not

Question 28

steps to rx in ectopic pregnancy

Answer 28

1. WATCHFUL WAITING
2. DRUGS for symptomatic
3. SURGICAL RX

Question 29

why is watchful waiting done in ectopic pregnancy

Answer 29

in early asymptomatic cases the pregnancy may spontaneously miscarry

Question 30

which drugs used in symptomatic pt in ectopic pregnancy

Answer 30

Methotrexate=> destroys rapidly divinding cells i.e. embryo, tumours i

(ts a folic acid antagonist that interferes for DNA synthesis. inhibits rapidly dividing cells. stops proliferation of the trophoblastic cells.)

Question 31

how is methotrexate admin in ectopic pregnancy

Answer 31

single intramuscular dose or in multiple doses with folic acid.

check hCG levels every 2 to 4 days until they begin to decrease.

Once falling, then hCG levels can be checked weekly to ensure completion

Question 32

methotrexate success rate in ectopic pregnancy

Answer 32

(73% to 94%)

Question 33

which factors decrease effectivness of methotrexate in ectopic pregnancy

Answer 33

1. ectopic pregnancies >3.5 cm
2. fetal cardiac activity
3. high hCG levels

Question 34

indication of surgical rx of ectopic preg=

Salpingectomy & salpingostomy

Answer 34

hemodynamic instability d/2 rupture and hemmgg contained products of conception within female genital tract

• Laproscopic – preferred
• Laparatomy If the pregnancy is within the fallopian tube

Question 35

complications of salpingectomy in ectopic pregnancy

Answer 35

• causes infertility
• The tube is severely damaged
• Bleeding may not be controlled
• The ectopic fetus is in a fallopian tube where an ectopic occurred previously

Question 36

usual location of ectopic preg

Answer 36

tubal ampulla 99%

Question 37

rare forms of ectopic preg

Answer 37

1. Ovarian pregnancy
2. Cervical pregnancy
3. Pregnancy in CS scar
4. Abdominal pregnancy (intestines)
5. Heterotopic pregnancy = ectopic pregnancy and intrauterine pregnancy occur simultaneously.

Question 38

dx of ectopic preg (1st trimester bleeds)

Answer 38

viable

1. miscarriage

non viable

1. implantation bleed
2. molar preg

Question 39

what is chandelier sign

Answer 39

Cervical motion tenderness or cervical excitation is a sign found on a gynecological pelvic examination suggestive of pelvic pathology

. Classically, it is present in the setting of pelvic inflammatory disease (PID) or ectopic pregnancy and is of some use to help differentiate PID from appendicitis.

It is also known colloquially as chandelier sign due to the pain being so excruciating upon bimanual pelvic exam (a part of a woman’s physical examination where two fingers are used to feel the anatomy of the pelvis) that it is as if the patient reaches up to motion the grabbing of a ceiling-mounted chandelier.