EXAM #1: ECTOPIC PREGNANCY

Question 1

What is the most common location for an ectopic pregnancy?

Answer 1

Fallopian tubes

Question 2

What is the most common cause of 1st trimester MATERNAL deaths?

Answer 2

Ectopic pregnancy

Question 3

What is the racial disparity regarding ectopic pregnancies?

Answer 3

Black women have 5x more mortality

Question 4

Why is the prevalence of ectopic pregnancies increasing?

Answer 4

1) Early detection
2) Increased PID
3) In vitro fertilization

Question 5

What women are at high risk for ectopic pregnancy?

Answer 5

1) Prior ectopic pregnancy
2) Hx. of tubal ligation (esp. cautery) or tubal reconstruction
3) IUD

Prior tubal surgery of any kind puts patients at the highest risk

Question 6

What women are at moderate risk for ectopic pregnancy?

Answer 6

1) PID
2) Infertility
3) Multiple partners
4) Smoking

Question 7

What women are at a slight risk for ectopic pregnancy?

Answer 7

1) In vitro fertilization
2) Older than 35
3) Prior spontaneous abortion

Question 8

When do you need to consider the diagnosis of ectopic pregnancy?

Answer 8

1) First trimester bleeding

2) Lower abdominal/pelvic pain

Question 9

How are ectopic pregnancies diagnosed?

Answer 9

Transvaginal US + beta-hCG

• BhCG quant 1500-2000
• NO intrauterine pregnancy

Question 10

What is the timeframe that you should start to be concerned about ectopic pregnancy?

Answer 10

1) 5-6 weeks since LNMP

2) 2 weeks since positive urine pregnancy test

Question 11

What lab could also be drawn in the ED in addition to BhCG when an ectopic pregnancy is suspected?

Answer 11

Progesterone

Question 12

What progesterone level indicates an abnormal pregnancy?

Answer 12

Less than 5 ng/mL

Question 13

What progesterone level indicates a normal intrauterine pregnancy?

Answer 13

Greater than 25 ng/mL

Question 14

You order a BhCG and get 2500. What do you expect?

Answer 14

Intrauterine pregnancy via TVUS

Question 15

You order a BhCG and get 6000. What do you expect?

Answer 15

Intrauterine pregnancy via abdominal US

Question 16

What is the discriminatory zone of β-HCG?

Answer 16

Level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy

*For TVUS this is 1500-1700

Question 17

What drug is indicated in the setting of an UNRUPTURED ectopic pregnancy?

Answer 17

Methotrexate

Question 18

What surgical procedures are indicated in the setting of an ectopic pregnancy?

Answer 18

1) Salpingectomy= removal of the fallopian tube
2) Salpingotomy= make an opening in the fallopian tube

*Note that there is NOT a big difference between future intrauterine pregnancy with these two; however, risk of ectopic is higher with salpingotomy

Question 19

What are the absolute indications for methotrexate?

Answer 19

1) Hemodynamically stable
2) Non-laproscopic diagnosis
3) Desires future fertility
4) General anesthesia poses a risk to the patient
5) Patient able to comply with treatment
6) No contraindications to methotrexate

Question 20

What are the absolute contraindications to methotexate?

Answer 20

1) Breastfeeding
2) Immune deficiency
3) Chronic liver disease
4) Pre-existing blood dyscrasias
5) Known sensitivity to Methotrexate
6) Acute pulmonary disease
7) Peptic ulcer disease

Question 21

What are the relative contraindications to methotrexate?

Answer 21

1) Unrupture mass GREATER than 3.5cm
2) Fetal cardiac activity identified
3) Quant BHCG between 6,000 - 15,000

Question 22

How do you follow a patient that has been given Methotrexate?

Answer 22

1) Serial B-HCG
2) If no decline, repeat dose or surgery
3) If decrease, follow until B-HCG

Question 23

What is a complication of Methotrexate that can lead to a diagnostic dilemma?

Answer 23

Methotrexate can INCREASE abdominal pain (concerning for rupture of ectopic)

Question 24

What are signs of Methotrexate failure?

Answer 24

1) Significantly worsening abdominal pain
2) Instability
3) B-HCG NOT declining by day 7
4) Increased or plateau in B-HCG by day 7

Question 25

What is the recurrence rate for an ectopic pregnancy? What are the clinical implications?

Answer 25

• 15-20% recurrence rate

- Monitor with B-HCG and serial TVUS