Ectopic_Pregnancy_Flashcards
What is the definition of an ectopic pregnancy?
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy.
What is the typical history of a patient with an ectopic pregnancy?
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding.
What are the symptoms of ectopic pregnancy related to lower abdominal pain?
Lower abdominal pain due to tubal spasm is typically the first symptom. The pain is usually constant and may be unilateral.
What are the characteristics of vaginal bleeding in ectopic pregnancy?
Vaginal bleeding is usually less than a normal period and may be dark brown in colour.
What is the significance of a history of recent amenorrhoea in ectopic pregnancy?
A history of recent amenorrhoea, typically 6-8 weeks from the start of the last period, suggests ectopic pregnancy. If longer (e.g., 10 weeks), it suggests other causes such as inevitable abortion.
What can peritoneal bleeding cause in ectopic pregnancy?
Peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination.
What are other possible symptoms of ectopic pregnancy?
Dizziness, fainting or syncope, and symptoms of pregnancy such as breast tenderness may also be reported.
What are the examination findings in ectopic pregnancy?
Examination findings include abdominal tenderness and cervical excitation (cervical motion tenderness).
What does an adnexal mass indicate in the examination of ectopic pregnancy?
NICE advises NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended.
What serum bHCG levels point toward a diagnosis of ectopic pregnancy in case of pregnancy of unknown location?
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy.
summarise ectopic pregnancy
Ectopic pregnancy
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain
due to tubal spasm
typically the first symptom
pain is usually constant and may be unilateral.
vaginal bleeding
usually less than a normal period
may be dark brown in colour
history of recent amenorrhoea
typically 6-8 weeks from the start of last period
if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
dizziness, fainting or syncope may be seen
symptoms of pregnancy such as breast tenderness may also be reported
Examination findings
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound reveals a 24mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She is given the option of expectant management but declines this.
What is the first line treatment?
Methotrexate
76%
Urgent laparoscopic salpingectomy
7%
Methotrexate + urgent laparoscopic salpingectomy
3%
Misoprostol
7%
Mifepristone
6%
A 19-year-old woman has a positive pregnancy test and is found to have an ectopic pregnancy after an intrauterine pregnancy is excluded. She has no pain or other symptoms at this time. Her serum beta-human chorionic gonadotropin (B-hCG) level is 877 IU/L. A transvaginal ultrasound reveals a 24mm adnexal mass but no heartbeat. There is no free fluid in the abdomen. She is given the option of expectant management but declines this.
What is the first line treatment?
Methotrexate
Urgent laparoscopic salpingectomy
Methotrexate + urgent laparoscopic salpingectomy
Misoprostol
Mifepristone
Methotrexate
The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up.
Expectant management is an option for a small number of women with a low B-hCG, no symptoms and tubal ectopic pregnancy measuring less than 35 mm with no heartbeat. However, this woman has declined this option.
Methotrexate is an antimetabolite chemotherapeutic drug. It interferes with DNA synthesis and disrupts cell multiplication thus preventing the pregnancy from developing.
The other treatment option is laparoscopic salpingectomy (or salpingotomy where there is risk of infertility). This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.
Misoprostol and mifepristone are not used in the management of ectopic pregnancy.
