Extra-uterine Pregnancy

Question 1

What is extrauterine pregnancy?

Answer 1

The implantation of a fertilized ovum outside the uterine cavity

Also known as ectopic pregnancy, derived from the Greek word ‘ektopos’, meaning out of place.

Question 2

What percentage of all pregnancies are affected by extrauterine pregnancy?

Answer 2

Approximately 1-2%

This statistic highlights the relative rarity of ectopic pregnancies.

Question 3

What is the classic clinical triad of ectopic pregnancy?

Answer 3

• Amenorrhoea
• Abdominal pain
• Vaginal bleeding

This triad occurs in only 50% of patients.

Question 4

What are the types of extrauterine pregnancy?

Answer 4

• Tubal
• Ovarian
• Abdominal
• Cervical

Tubal ectopic pregnancy accounts for 97% of cases, with up to 80% occurring in the ampulla.

Question 5

What are common risk factors for ectopic pregnancy?

Answer 5

• Chronic pelvic inflammatory disease (PID)
• History of previous pelvic surgery
• Maternal in-utero diethylstilbestrol (DES) exposure
• History of previous ectopic pregnancy
• Smoking
• Increased maternal age
• Uterine anomalies
• Salpingitis isthmica nodosum
• Failed contraception

Most diagnosed women have no identifiable risk factor.

Question 6

What is the significance of serum β-hCG levels in diagnosing ectopic pregnancy?

Answer 6

In ectopic pregnancies, the mean serum β-hCG levels are lower than in healthy pregnancies

Normal pregnancy β-hCG levels double every 48-72 hours.

Question 7

What is the discriminatory zone of β-hCG for transvaginal ultrasound (USS)?

Answer 7

1500-1800 IU/L

This is the level above which an imaging scan should reliably visualize an intrauterine pregnancy.

Question 8

What is the most important tool for diagnosing extrauterine pregnancy?

Answer 8

Ultrasonography (USS)

Diagnosis is usually confirmed by visualization of an intrauterine sac.

Question 9

What are the prerequisites for successful expectant management of ectopic pregnancy?

Answer 9

• Asymptomatic
• No evidence of rupture
• Initial β-hCG level < 1,500 IU/L
• Haemodynamically stable
• Objective evidence of resolution

Close follow-up and patient compliance are crucial.

Question 10

What is the standard medical treatment for unruptured ectopic pregnancy?

Answer 10

Methotrexate (MTX)

The regimen may be a single dose or multiple doses.

Question 11

What surgical approach is recommended for most cases of ectopic pregnancy?

Answer 11

Laparoscopy

Laparotomy is reserved for haemodynamically unstable patients or those with cornual ectopic pregnancies.

Question 12

What is a heterotopic pregnancy?

Answer 12

The simultaneous occurrence of an extrauterine and intrauterine pregnancy

Occurs in 1 in 30,000 pregnancies of natural conceptions.

Question 13

True or False: Ectopic pregnancy is the commonest cause of maternal mortality in early pregnancy.

Answer 13

True

Its incidence is rising, but maternal mortality is falling due to modern diagnostic techniques.

Question 14

Fill in the blank: The initial β-hCG level for medical management of ectopic pregnancy should be _______.

Answer 14

< 5,000 IU/L

This is one of the prerequisites for medical treatment.

Question 15

What should be done if an empty uterus is found on USS with a β-hCG level above the discriminatory cut-off?

Answer 15

Consider it an ectopic pregnancy until proved otherwise

This emphasizes the importance of careful diagnosis.

Question 16

What are some differential diagnoses for ectopic pregnancy?

Answer 16

• Appendicitis
• Salpingitis
• Ruptured corpus luteum cyst
• Spontaneous abortion or threatened abortion
• Ovarian torsion
• Urinary tract disease

These conditions can mimic the symptoms of ectopic pregnancy.

Question 17

Tubal Ectopic pregnancy can be divided into three;

Answer 17

Ampulla (80%)
Isthmic (12%)
Fimbrial (5%)

Question 18

Examination findings in women with ectopic pregnancy

Answer 18

Evidence of hypovolemic shock
Abdominal signs – Severe tenderness; rigidity; involuntary guarding
Uterine or cervical excitation tenderness
Palpable adnexal mass

Question 19

In a normal pregnancy, the β-hCG level doubles every 48-72 hours until it reaches _____-______mIU/mL.

Answer 19

10000-20000

Question 20

The discriminatory zone of β-hCG, above which an intrauterine pregnancy should reliably be visualized, is —— with transvaginal ultrasound and——- with transabdominal ultrasound.

Answer 20

1500–1800 IU/L

6000–6500 IU/L

Question 21

How are ectopic pregnancies confirmed?

Answer 21

An empty uterus on USS in patients with a serum β-hCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proved otherwise.

Question 22

MTX regimen in ectopic pregnancy can be in what dose

Answer 22

single or multiple dose

Question 23

Prerequisites for the use of methotrexate

Answer 23

Hemodynamic stability
Initial β-hCG level ˂ 5,000 IU/L
No severe or persisting abdominal pain
The ability to follow up multiple times
Normal baseline liver and renal function test results

Question 24

For a Pre-treatment Work-up in patient with ectopic pregnancy, you check for the following:

Answer 24

• Quantitative β-hCG levels
• Full Blood Count
• Liver Function Test
• Renal Function Test
• Blood grouping & cross-matching - To identify patients who need RhoGAM (Rh-negative) and to ensure availability of blood products in case of excessive blood loss.

Question 25

—— is the recommended surgical approach in most cases of ectopic pregnancy.

Answer 25

Laparoscopy

Question 26

Laparotomy is usually reserved for the following scenario in ectopic pregnancies where:

Answer 26

Patients who are haemodynamically unstable
Patients with cornual ectopic pregnancies
For surgeons inexperienced in laparoscopy and
In patients in whom a laparoscopic approach is difficult.

Question 27

Options of Surgical Laparoscopic Treatment in ectopic pregnancies

Answer 27

Conservative
Linear salpingostomy
Salpingotomy
Partial salpingectomy

Definitive
Total salpingectomy

Question 28

All tubal ectopic pregnancy can be treated by partial or total salpingectomy

Salpingostomy/salpingotomy is only indicated when:

Answer 28

The patient is haemodynamically stable
Tubal pregnancy is accessible
Unruptured and ˂5cm in size
Contralateral tube is absent or damaged

Question 29

Differential diagnosis of ectopic pregnancies

Answer 29

The most common of these include the following:
Appendicitis
Salpingitis
Ruptured corpus luteum cyst
Spontaneous abortion or threatened abortion
Ovarian torsion
Urinary tract disease