EXTRA-UTERINE PREGNANCY Flashcards
What is extrauterine pregnancy?
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.
What percentage of all pregnancies are affected by extrauterine pregnancy?
Approximately 1-2%
This statistic highlights the relative rarity of ectopic pregnancies.
What is the classic clinical triad of ectopic pregnancy?
- Amenorrhoea
- Abdominal pain
- Vaginal bleeding
This triad occurs in only 50% of patients.
What are the types of extrauterine pregnancy?
- Tubal
- Ovarian
- Abdominal
- Cervical
Tubal ectopic pregnancy accounts for 97% of cases, with up to 80% occurring in the ampulla.
What are common risk factors for ectopic pregnancy?
- 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.
What is the significance of serum β-hCG levels in diagnosing ectopic pregnancy?
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.
What is the discriminatory zone of β-hCG for transvaginal ultrasound (USS)?
1500-1800 IU/L
This is the level above which an imaging scan should reliably visualize an intrauterine pregnancy.
What is the most important tool for diagnosing extrauterine pregnancy?
Ultrasonography (USS)
Diagnosis is usually confirmed by visualization of an intrauterine sac.
What are the prerequisites for successful expectant management of ectopic pregnancy?
- 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.
What is the standard medical treatment for unruptured ectopic pregnancy?
Methotrexate (MTX)
The regimen may be a single dose or multiple doses.
What surgical approach is recommended for most cases of ectopic pregnancy?
Laparoscopy
Laparotomy is reserved for haemodynamically unstable patients or those with cornual ectopic pregnancies.
What is a heterotopic pregnancy?
The simultaneous occurrence of an extrauterine and intrauterine pregnancy
Occurs in 1 in 30,000 pregnancies of natural conceptions.
True or False: Ectopic pregnancy is the commonest cause of maternal mortality in early pregnancy.
True
Its incidence is rising, but maternal mortality is falling due to modern diagnostic techniques.
Fill in the blank: The initial β-hCG level for medical management of ectopic pregnancy should be _______.
< 5,000 IU/L
This is one of the prerequisites for medical treatment.
What should be done if an empty uterus is found on USS with a β-hCG level above the discriminatory cut-off?
Consider it an ectopic pregnancy until proved otherwise
This emphasizes the importance of careful diagnosis.
What are some differential diagnoses for ectopic pregnancy?
- 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.
Tubal Ectopic pregnancy can be divided into three;
Ampulla (80%)
Isthmic (12%)
Fimbrial (5%)
Examination findings in women with ectopic pregnancy
Evidence of hypovolemic shock
Abdominal signs – Severe tenderness; rigidity; involuntary guarding
Uterine or cervical excitation tenderness
Palpable adnexal mass
In a normal pregnancy, the β-hCG level doubles every 48-72 hours until it reaches _____-______mIU/mL.
10000-20000
The discriminatory zone of β-hCG, above which an intrauterine pregnancy should reliably be visualized, is —— with transvaginal ultrasound and——- with transabdominal ultrasound.
1500–1800 IU/L
6000–6500 IU/L
How are ectopic pregnancies confirmed?
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.
MTX regimen in ectopic pregnancy can be in what dose
single or multiple dose
Prerequisites for the use of methotrexate
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
For a Pre-treatment Work-up in patient with ectopic pregnancy, you check for the following:
- 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.
—— is the recommended surgical approach in most cases of ectopic pregnancy.
Laparoscopy
Laparotomy is usually reserved for the following scenario in ectopic pregnancies where:
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.
Options of Surgical Laparoscopic Treatment in ectopic pregnancies
Conservative
Linear salpingostomy
Salpingotomy
Partial salpingectomy
Definitive
Total salpingectomy
All tubal ectopic pregnancy can be treated by partial or total salpingectomy
Salpingostomy/salpingotomy is only indicated when:
The patient is haemodynamically stable
Tubal pregnancy is accessible
Unruptured and ˂5cm in size
Contralateral tube is absent or damaged
Differential diagnosis of ectopic pregnancies
The most common of these include the following:
Appendicitis
Salpingitis
Ruptured corpus luteum cyst
Spontaneous abortion or threatened abortion
Ovarian torsion
Urinary tract disease
