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My MRCOG Part 2 > Module 13: Ectopic Pregnancy > Flashcards

Module 13: Ectopic Pregnancy Flashcards

NICE, GTG and TOGs

1
Q

What is the incidence of ectopic pregnancies in the UK?

A

1:11,000 (1% of pregnancies)
Approx 11,000 ectopics per year.
2-3% of EPAU attendances.

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2
Q

What are the risk factors for developing ectopic pregnancy?

A
  1. Tubal damage (surgery or infection).
  2. Smoking.
  3. IVF.
  4. Idiopathic (majority of cases).
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3
Q

What proportion of ectopic pregnancies are tubal?

A

95%

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4
Q

What is the chance of ectopic pregnancy in a woman with a positive UPT and smooth walled anechoic cystic structure within the uterus?

A

0.02%

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5
Q

In what proportion of ectopic pregnancies is echogenic fluid reported?

A

28-56%
(may signify blood from the fimbrial end).

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6
Q

What are diagnostic criteria for tubal ectopic pregnancy?

A
  1. Adnexal mass moving separate to ovary.
  2. Double decidual sign.
  3. Intra-decidual sign
  4. Pseudosac (only present in 20% cases).
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7
Q

What is the double decidual sign?

A

Intra-uterine fluid collection surrounded by 2 concentric echogenic rings.

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8
Q

What is the intra-decidual sign?

A

Fluid collection with echogenic rim within a markedly thickened decidua on ONE SIDE of the uterus.

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9
Q

What is the sensitivity and specificity of US in tubal ectopic pregnacy?

A

Sensitivity: 87-99%.
Specificity: 94-99.9%.

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10
Q

What is the false negative rate for diagnostic laparoscopy for ectopic pregnancy?
What is the reason for false negatives?

A

3-4%.

Pregnancies that are too early.

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11
Q

What are the diagnostic criteria for cervical ectopic pregnancy?

A
  1. Empty Uterus.
  2. Barrel shaped cervix.
  3. Gestational sac below level of internal os (with blood flow around internal os).
  4. ABSENCE of sliding sign.
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12
Q

What is the sliding sign?

A

Gentle pressure applied to TVUS causes sac to slide up and down in an aborting pregnancy.
(Will not move in cervical ectopic).

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13
Q

What is the incidence of uterine scar ectopic?

A

1:2,000 pregnancies.
(increasing incidence)/

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14
Q

What proportion of cervical ectopic are initially mis-diagnosed as IUP or cervical ectopics?

A

13%

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15
Q

What are the US criteria of uterine scar ectopics?

A
  1. Empty uterine cavity.
  2. Gestational sac or trophoblast mass anteriorly at level of internal os.
  3. Thin or absent myometrium between gestational sac and bladder.
  4. Prominent trophoblastic or placental circulation of Doppler.
  5. Empty endocervical canal.
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16
Q

Define an interstitial ectopic pregnancy.

A

A pregnancy that is developing in the uterine part of the fallopian tube.

(i.e. 1-2cm length of transverse muscular myometrium of uterine wall that opens via ostium into uterine cavity).

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17
Q

What proportion of ectopic pregnancies are interstitial?

A

1-6%

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18
Q

What are the US criteria for diagnosing an interstitial pregnancy?

A
  1. Empty uterus.
  2. POC/sac seen laterally to interstitial (AKA intramural) part of the tube.
  3. Surrounded by <5mm myometrium in all planes.
  4. Interstitial line sign.
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19
Q

How can 3D US be used in the diagnosis of interstitial ectopics?

A

To differentiate between interstitial ectopic, early IUP or angular pregnancies.

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20
Q

What findings support diagnosis of interstitial ectopic pregnancy on MRI?

A
  1. Sac seen lateral to corua surrounded by myometrium.
  2. Intact junctional (endomyometrial) zone between uterus and sac.
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21
Q

What is the recommended treatment of cornual pregnancy?

A

Laparoscopic removal of accessory horn.

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22
Q

How is ovarian ectopic diagnosed?

A

At laparoscopy and histology because US cannot differentiate between ectopic and ovarian cyst.
Corpus luteum should be seen separately.

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23
Q

What is a normal 48 hour bHCG rise?

A

> 63%

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24
Q

What is the overall risk of serious complication at diagnostic laparoscopy?

A

2 / 1,000

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25
Q

State the criteria for expectant management of ectopic pregnancy.

A
  1. US confirmed ectopic.
  2. Asymptomatic.
  3. No evidence of blood in POD (rupture).
  4. Decreasing bHCG.
  5. bHCG <1,000 initially.
  6. No FH on US.
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26
Q

State the criteria for methotrexate management.

A
  1. bHCG < 3,000.
  2. Minimal or asymptomatic.
  3. No FH.
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27
Q

What proportion of women receiving medical treatment for ectopic pregnancy will require a second dose of methotrexate?

A

14%

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28
Q

What proportion of women undergoing medical management of ectopic pregnancy will require later surgical management?

A

<10%

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29
Q

When should anti-D be given to women being treated for an ectopic pregnancy?

A
  1. Surgical management.
  2. Heavy repeated bleeding.
  3. PVB associated with abdominal pain.
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30
Q

What is the risk of alloimmunisation in ruptured ectopic pregnancies?

A

25%

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31
Q

When is medical treatment of cervical ectopic pregnancy likely to fail?

A
  1. > 9 / 40
  2. bHCG > 10,000
  3. CRL > 10mm
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32
Q

What is the rate of a women having a successful, healthy, ongoing pregnancy after salpingectomy in presence of healthy contra-lateral tube?

A

60%

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33
Q

What is the rate of a women having a successful, healthy, ongoing pregnancy after salpinGOSTomy in presence of healthy contra-lateral tube?

A

57%

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34
Q

What is the risk of persistent trophoblastic tissue following salpingectomy vs salpingostomy?

A

1% salpingectomy
7% salpingostomy.

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35
Q

What is the risk of repeat ectopic pregnancy following salpingectomy vs salpingostomy?

A

5% salpingectomy

8% salpingostomy

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36
Q

What is the rate of future pregnancy after SALPINGECTOMY in women with normal fertility vs women with fertility reducing factors?

A

Normal fertility - 90%
Fertility reducing factors - 40%

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37
Q

What is the rate of future pregnancy after SALPINGOSTOMY in women with normal fertility vs women with fertility reducing factors?

A

Normal fertility - 90%
Fertility reducing factors - 70%

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38
Q

What are criteria for receiving methotrexate treatment?

A
  1. Asymptomatic
  2. Ectopic on US - Unruptured
  3. <35mm
  4. bHCG 1500-5000
  5. Empty uterus
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39
Q

What is the success rate of methotrexate treatment for ectopic pregnnacies?

A

65-95% success

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40
Q

What proportion of women will require a second dose of methotrexate treatment for ectopic pregnnacy?

A

3-27%

(14% quoted in most sources)

41
Q

When should bHCG be measured after giving methotrexate for ectopic pregnancy?

A

Day 4 and 7.

If decrease more than 15% then measure weekly until negative.

If decrease <15% then rescan (exclude haemoperitoneum and FH) and consider a second dose.

42
Q

What are the side effects of methotrexate treatment (including the most common)?

A

Most common = flactulence and bloating.
Transient rise in LFTs.
Stomitis.

Also, bone marrow suppression, pulmonary fibrosis, non-specific pneumonitis, liver chirrhosis, renal failure and peptic ulcer.

43
Q

What is the chance of successful medical management with bHCG <1000 vs >5000?

A

<1,000 - 81-98% success.
>5,000 - 38% success.

(also higher chance of success with smaller rise in pre treatment bHCG rise).

43
Q

What is the chance of methotrexate being successful when D1 to D4 bHCG decreases vs when D1 to D4 bHCG increases?

A

Decreasing bHCG - 88-100% success.

Increased bHCG - 42-62%

43
Q

Is methotrexate or surgery more effective at treating tubal ectopic pregnancies? (As seen in multiple RCTs)

A

RCTs have shown they have the same efficacy.
(careful patient selection?)

44
Q

What is the overall success rate for expectant management of ectopic pregnacy?

A

72% (57-100%)

45
Q

What is the difference in effect on future subfertility between expectant, medical or surgical management?

A

No difference in future subfertility or tubal pathology based on treatment method.

46
Q

For women with a history of sub-fertility, what management options for ectopic pregnancy are associated with better reproductive outcomes?

A

Expectant and Medical managements have better future reproductive outcomes in women with a history of sub-fertility. Particularly in women >35 years.

47
Q

Does methotrexate affect a woman’s ovarian reserve?

A

No.

48
Q

How long should women wait to attempt to conceive again after methotrexate treatment?

A

3 months

49
Q

What is the IM dose of Methotrexate for ectopic pregnancies?

A

50mg/m²

50
Q

What is the risk of a further ectopic pregnancy after medical management of tubal ectopic pregnancy?

A

10 - 18%

51
Q

What complimentory therapy, when given alongside methotrexate, has been shown in increase the success rate of medical management of tubal ectopic pregnancy?

A

Muscle relaxant training.
(MAY be of use).

52
Q

What US sign is generally seen with an ovarian ectopic pregnancy?

A

Wide echogenic ring with internal anaechoic area.
Foetal pole and FH are very rarely seen.

53
Q

What are the treatment options for ovarian ectopic pregnancy?

A

Medical management - 60% success rate.

Surgical - POC Enucliation, Wedge resection or oophrectomy.

54
Q

What are the 2 type of caesarean scar ectopic?

A

Type 1 - Endogenic (growing into uterine cavity)

Type 2 - Exogenic (growing outwards towards the bladder)

55
Q

What is the general consensus for management of uterine scar ectopic?

A

There isn’t a general consensus.

Options include:
Systemic methotrexate,
Local methotrexate with or without sac aspiration,
Hysteroscopic removal,
Laparoscopic removal and scar revision.

56
Q

What are the management options for heterotopic ectopic pregnancies?

A
  1. Expectant if non viable pregnancies.
  2. Medical only if IUP not wanted. Or local injection to the ectopic pregnancy.
  3. Surgical either to inject and aspirate sac or salpingectomy.
57
Q

When locally injecting ectopics before aspiration of the sac, what substances can be used?

A

KCL
Hyperosmolar glucose
Methotrexate

58
Q

What is an interstitial pregnancy also known as?

A

Cornual pregnancy

59
Q

What is the mortality rate of interstitial ectopic pregnancy when compared to tubal ectopic pregnancies?

A

5x higher

Because can grow more before symptoms, therefore, likely to present at a later gestation and have a more extensive vascular network that includes uterine- ovarian anastamoses.

60
Q

What is the gold standard treatment for interstitial ectopic pregnancies?

A

Laparoscopic Surgical Removal

(cornual resection and cornusotomy with or without salpingectomy)

Endo GIA Stapler normally used for this.

61
Q

What is EAP and AAP?

A

Early Abdominal Pregnancy
Advanced Abdominal Pregnancy

62
Q

What is the maternal mortality rate of abdominal pregnancy in recent years?
What is the foetal survival rate?

A

0 - 12% maternal mortality

80% foetal survival

63
Q

What is the typical presentation of abdominal pregnancy?

A

There isn’t one!!
Depends on where pregnancy is.

64
Q

What are the US signs of abdominal pregnancy?

A

-Anteriorly displaced cervix.
-Bloating
-Persistent vomiting
-Severe anaemia
-Abnormal foetal lie
-Oligo hydramnios (therefore pulmonary HTN and compressive deformities in baby)
-SGA

65
Q

What is the recommended treatment of early abdominal pregnancy (abdominal ectopic)?

A

TOP

66
Q

What is the recommended treatment of advanced abdominal pregnancy (AAP)?

A

If found at viability, may wait until acceptable gestation for fetal survival before operating.
MRI to determine location and where structures have attached.
Treatment should be para/midline laparotomy under GA.
If pre-viability, consider feticide and TOP.

67
Q

What is the rate of hysterectomy in women undergoing a laparotomy with an advanced abdominal pregnancy?

A

13%

68
Q

What is the rate of BSO in women undergoing laparotomy for advanced abdominal pregnancy?

A

13%

69
Q

Where does the placenta most commonly invade in cases of advanced abdominal pregnancy?

A

The uterus and adnexa

(?due to stale blood supply).

70
Q

What is the consensus RE placental delivery in women undergoing laparotomy for advanced abdominal pregnancy?

A

There is NO consensus.
Dictated by organs placenta is attached to.

71
Q

How long on average, does it take for a placenta to be re-absorbed after advanced abdominal pregnancy?

A

5.5 years
(bHCG returns to normal after 10 days to 7 weeks).

Methotrexate IM can speed this up.

72
Q

What are the risks and benefits of UAE when treating AIP or advanced abdominal pregnancy?

A

Reduces bleeding.

But may increase rates of ileus, infection and bowel perforation.

73
Q

For women undergoing laparotomy for advanced abdominal pregnancy, what is the chance of requiring an intra-operative blood transfusion?

A

70 - 90%

74
Q

Define Lithopedion

A

An abdominal pregnancy (likely unnoticed) that had died intra-abdominally and then the abdomen calcifies it.

75
Q

What is the incidence of early abdominal pregnancies and what proportion of ectopic pregnancies does this represent?

A

1% all ectopic pregnancies

1 in 6 -9,000 live births
1 in 2-10,000 pregnancies

76
Q

What is the overall mortality rate of early abdominal pregnancy?
How does this compare to tubal ectopic and IUP?

A

<5% (down from 20%)

8x higher than tubal ectopic pregnancy
90x higher than IUP

77
Q

What gestation defines early and advanced (aka late) abdominal pregnancy?

A

Early 20/40 or less

Advanced >20/40.

78
Q

Combination of US and clinical assessment gives what accuracy of detecting early abdominal pregnancy?

A

50%

79
Q

What are the two types of early abdominal pregnnacy?

A

Primary (directly implants into abdominal cavity or organs)

Secondary (extruded from tube then implants into abdomen. Eg when ovulation occurs near the time of menstruation).

80
Q

What are the medical management options of early abdominal pregnancy?

A
  • Methotrexate
  • Local KCL or hyperosmolar glucose injection
  • Prostaglandins
  • Danazol (GnRH antagonist)
  • Etopiside (chometherpy)
  • Mifeprostone
81
Q

What proportion of ectopic pregnancies (in women with a previous LSCS) are scar ectopics?

A

6% of ectopics in women with a previous LSCS are scar ectopics.

82
Q

Is there a correlation between risk of scar ectopic and number of previous LSCS?

A

NO.
Most scar ectopics occur in women who have had only one previous LSCS.

83
Q

What is the chance of recurrence after a uterine scar ectopic?

A

3-5%

84
Q

What factors increase the risk of uterine scar ectopics?

A

Uterine segment thickness <5mm
Type 2
LSCS in rural community
Hx of irregular PVB and abdominal pain in previous CSP.

85
Q

What US Doppler findings are consistent with functional trophoblastic tissue?

A

High velocity and low resistance

86
Q

What is the failure rate of expectant management of uterine scar ectopic? What is the risk of these women requiring a hysterectomy?

A

70% failure

30% need a hysterectomy.

87
Q

What is the success rate of treatment of uterine scar with a combination of systemic and local methotrexate?

A

74%

88
Q

What is the overall risk of serious injury in laparoscopic procedures?

A

2 / 1,000
(0.5%)

89
Q

What are the risks of:
- bowel injury
- vascular injury
- death
during laparoscopic surgery?

A

Risk of bowel injury 0.4/1000

Risk of vascular injury 0.2/1000

Risk of death is 5 (3 - 8) in 100,000

90
Q

What is the risk of persistent trophoblastic tissue after sapingotomy?
What proportion of these patients need further treatment?

A

4 - 8%

20 of those need further treatment.

91
Q

Which patients should be encouraged to self refer to EPAU after a positive UPT?

A

Women with recurrent miscarriage, previous ectopic or previous molar pregnancy.

92
Q

What proportion of ectopic pregnancies occur in women with no risk factors?

A

1 in 13.

93
Q

When should TAUS be used over TVUS in diagnosis of miscarriage or ectopic?

A

Enlarged uterus,
Pelvic pathology (eg large fibroids or cyst)
Patient choice

94
Q

What is the maternal mortality rate for ectopic pregnancies?

A

0.2 / 1,000
(2 in 10,000)

95
Q

What is the leading cause of death in women presenting with ectopic pregnancies?

A

They get thrombolised in ED as a presumed PE and die of intra-abdominal heamorrhage.
Therefore FASP scans should be readily available in ED!

96
Q

What dose of Anti-D should be given?

A

250IU (5mg)
to anyone with ruptured ectopic or surgical management.

97
Q

What is the risk of future ectopic pregnancy after ectopic pregnancy diagnosed and treated?

A

18.5%
Regardless of treatment modality.

My MRCOG Part 2 (37 decks)

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