Ectopic pregnancy – types. Tubal pregnancy – causes, symptoms, differential diagnosis, management. Flashcards
what is an ectopic pregnancy
Implantation of the embryo outside of the uterus. Occurs in 2% of pregnancies most common pregnancy related cause of death in 1 st trimester
how does ectopic pregnancy happen
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.
what determines the development of the embryo in an ectopic pregnancy
the blood supply of the implanted area
what happens if the area is poorly supplied in ectopic pregnancy
Tissue cannot provide a sufficient blood supply to support an embryo ==> DEATH
rich blood suply of ectopic area
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
consequences of ectopic embryo expansion
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
which consequences of ectopic embryo expansion are medical emergencies
Internal bleeding Severe pain Damage to fallopian tube
risk factors of ectopic pregnancies
- 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
what does the clinical presentation depend on in ectopic pregnancy
- The location of the ectopic pregnancy 2. Symptomatic / asymptomatic 3. Rupture
clinical symptoms of ectopic pregnancy
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
what determines the physical exam in ectopic pregnancy
whethere there is rupture or not
presentation of ruptured ectopic pregnancy
- tachycardia
- hypovolemic shock signs
- hypotension, cold skin, etc
- acute abdomen d/2 haemoperitoneum
- distention -guarding -rebound tenderness -cervical motion tenderness (chandelier sign)
physical exam in abscence of rupture
normal
dg for ectopic pregnancy
- B HCG: normal lvs Rapidly increased suring the 1st trimester of pregnancynand doubles every 2 days if pregnancy is viable until 12 wks
- US : check for presence of gestational sac by 6th week once hcg is at discriminative zone
- D&C: check for chorionic villi
- serum progesterone: should be over 25 ng/l if viable
- laparoscopy: confirmatory dg
how B HCG os used in ectopic pregnancy
Rapidly increased suring the 1st trimester of pregnancy doubles every 2 days if pregnancy is viable
US in ectopic pregnancy
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
what is the discriminative zone
amount of b hcg above which intrauterine pregnancies should be visualised by US
what does it mean if thb hcg is above the discriminative zone but not seen on US
non viable preg
what does it mean If the quantitative hCG is below the discriminatory zone + ultrasound is nondiagnostic
follow serial quantitative hCG levels to distinguish a viable intrauterine pregnancy from a nonviable gestation
If hCG levels ^ above discriminatory zone
repeat US to confirm pregnancy
when & why is DC done in ectopic preg
- to look for Chorionic Villi
- when intrauterine not detected in US when hcg level is higher the discrimnatory zone
what does an abscence of chorionic villi in DC show when hcg is at discriminative zone
ectopic pregnancy
serum progesterone lvls in ectopic pregnancy
used as adjuct as they;re controvesial
lvl of progesterone in non viable pregnancies
less than 5ng/mL
lvl of progesterone in viable intrauterine pregnancies
25ng/mL
when is laparoscopy used in ectopic pregnancy
if doubt persists after the other methods of dg
what determines rx of ectopic
assx/ symps
ruptured or not
steps to rx in ectopic pregnancy
- WATCHFUL WAITING
- DRUGS for symptomatic
- SURGICAL RX
why is watchful waiting done in ectopic pregnancy
in early asymptomatic cases the pregnancy may spontaneously miscarry
which drugs used in symptomatic pt in ectopic pregnancy
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.)
how is methotrexate admin in ectopic pregnancy
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
methotrexate success rate in ectopic pregnancy
(73% to 94%)
which factors decrease effectivness of methotrexate in ectopic pregnancy
- ectopic pregnancies >3.5 cm
- fetal cardiac activity
- high hCG levels
indication of surgical rx of ectopic preg=
Salpingectomy & salpingostomy
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
complications of salpingectomy in ectopic pregnancy
- 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
usual location of ectopic preg
tubal ampulla 99%
rare forms of ectopic preg
- Ovarian pregnancy
- Cervical pregnancy
- Pregnancy in CS scar
- Abdominal pregnancy (intestines)
- Heterotopic pregnancy = ectopic pregnancy and intrauterine pregnancy occur simultaneously.
dx of ectopic preg (1st trimester bleeds)
viable
- miscarriage
non viable
- implantation bleed
- molar preg
what is chandelier sign
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.
