Gynecology

Question 1

Causes of ectopic pregnancy

Answer 1

1. 50% due to damage of Fallopian tube cilia following PID
2. Intrinsic abnormality of fertilized ovum
3. Conception late in cycle
4. Transmigration of fertilized ovum to contralateral tube

Question 2

Risk factors for ectopic pregnancy

Answer 2

1. Previous ectopic pregnancy
2. Current IUD use
3. History of PID (especially chlamydia infection), salpingitis
4. Infertility
5. Infertility treatment (IVF with ovulation induction)
6. Any surgery on Fallopian tube (i.e. tubal ligation)
7. Abdo surgery for ruptured appendix, etc.
8. Smoking
9. Structural: Uterine leiomyomas, adhesions, abnormal uterine shape

Question 3

Investigations for ectopic pregnancy

Answer 3

1. Serial b-hCG levels; normal doubling time with intrauterine pregnancy is every 48h in the first 8wks
   - rise of < 20% = non-viable pregnancy
   - prolonged doubling time, plateau, decreasing levels before 8wks = nonviable gestation
   - 85% of ectopics show abnormal b-hCG doubling
2. USS
   - only definitive if fetal cardiac activity is detected in tube or uterus
   - specific finding on transvaginal USS = tubal ring sign
3. Suspect ectopic in case of empty uterus by transvaginal USS with b-hCG > 2000-3000
4. Laparoscopy (sometimes used)

Question 4

Signs of suspected ectopic pregnancy

Answer 4

1. Positive urine b-hCG
2. Abdominal pain
3. Vaginal bleeding

Question 5

Treatment for ectopic pregnancy

Answer 5

1. Expectant
   - b-hCG levels low + declining
   - No fetal heartbeat/extrauterine sac suspicious of ectopic pregnancy
   - Pt reliable for follow-up
2. Methotrexate
   - < 3.5cm unruptured ectopic
   - No fetal heart rate
   - b-hCG < 5000
   - No hepatic/renal/hematological disease
   - Compliance assured + willing to follow-up
3. Surgery (laparoscopy - salpingostomy/salpingectomy)
   - Pt doesn’t meet criteria for medical management
   - Contraindication to methtrexate

Question 6

What are the contraindications to methotrexate therapy for ectopic pregnancy?

Answer 6

1. Abnormalities in hematological, hepatic, or renal function
2. Immunodeficiency
3. Active pulmonary disease
4. Peptic ulcer disease
5. Hypersensitivity to methotrexate
6. Heterotopic pregnancy with coexisting viable intrauterine pregnancy
7. Breastfeeding
8. Unwilling or unable to adhere to methotrexate protocol

Question 7

3 commonest locations for ectopic pregnancy

Answer 7

1. Ampulla (70%)
2. Isthmic (12%)
3. Fimbrial (11%)