Tubal Ectopic Pregnancy

Question 1

The most common site of ectopic pregnancy is the

Answer 1

fallopian tube

Question 2

The fallopian tube is the most common location of ectopic implantation, accounting for more than 90% of cases (4). However, implantation in the

Answer 2

abdomen (1%), cervix (1%), ovary (1–3%), and cesarean scar (1–3%) can occur and often results in greater morbidity because of delayed diagnosis and treatment

Question 3

An ectopic pregnancy also can co-occur with an intrauterine pregnancy, a condition known as ____. The risk of heterotopic pregnancy among women with a naturally achieved pregnancy is estimated to

Answer 3

heterotopic pregnancy
range from 1 in 4,000 to 1 in 30,000, whereas the risk among women who have undergone in vitro fertilization is estimated to be as high as 1 in 100

Question 4

The chance of a repeat ectopic pregnancy in a woman with a history of one ectopic pregnancy is approximately

Answer 4

10%

Question 5

In a woman with two or more prior ectopic pregnancies, the risk of recurrence increases to

Answer 5

more than 25%

Question 6

However, up to 53% of pregnancies that occur with an IUD in place are ectopic

Answer 6

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Question 7

Serial evaluation with transvaginal ultrasonography, or serum hCG level measurement, or both, often is required to confirm the diagnosis.

Answer 7

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Question 8

Women with clinical signs and physical symptoms of a ruptured ectopic pregnancy, such as hemodynamic instability or an acute abdomen, should be evaluated and treated urgently.

Answer 8

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Question 9

. Every sexually active, reproductive-aged woman who presents with abdominal pain or vaginal bleeding should be screened for pregnancy, regardless of whether she is currently using contraception

Answer 9

abdominal pain OR
vaginal bleeding
should be screened for pregnancy, regardless of whether she is currently using contraception

Question 10

Ultrasonography can definitively diagnose an ectopic pregnancy when a gestational sac with a yolk sac, or embryo, or both, is noted in the adnexa (15, 16); however, most ectopic pregnancies do not progress to this stage

Answer 10

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Question 11

Although a hypoechoic “sac-like” structure (including a “double sac sign”) (18) in the uterus likely represents an intrauterine gestation, it also may represent a pseudogestational sac, which is a collection of fluid or blood in the uterine cavity that is sometimes visualized with ultrasonography in women with an ectopic pregnancy

Answer 11

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pseudogestational sac

Question 12

An intrauterine gestational sac with a yolk sac should be visible between 5 weeks and 6 weeks of gestation regardless of whether there are one or multiple gestations (25, 26). In the absence of such definitive information, the serum hCG level can be used as a surrogate for gestational age to help interpret a nondiagnostic ultrasonogram.

Answer 12

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Question 13

The absence of a possible gestational sac on ultrasound examination in the presence of a hCG measurement above the discriminatory level strongly suggests a nonviable gestation (an early pregnancy loss or an ectopic pregnancy). I

Answer 13

discriminatory zone: 1500-2000

Question 14

If the concept of the hCG discriminatory level is to be used as a diagnostic aid in women at risk of ectopic pregnancy, the value should be conservatively high (eg, as high as 3,500 mIU/mL) to avoid the potential for misdiagnosis and possible interruption of an intrauterine pregnancy that a woman hopes to continue

Answer 14

3,500

Question 15

A single hCG concentration measurement cannot diagnose viability or location of a gestation. Serial hCG concentration measurements are used to differentiate normal from abnormal pregnancies (21, 22, 33, 34). When clinical findings suggest an abnormal gestation, a second hCG value measurement is recommended 2 days after the initial measurement to assess for an increase or decrease. Subsequent assessments of hCG concentration should be obtained 2–7 days apart, depending on the pattern and the level of change.

Answer 15

hcg must be measured q 2 days

subsequent assessments of HCG should be 2-7 days apart

Question 16

In early pregnancy, serum hCG levels increase in a curvilinear fashion until a plateau at 100,000 mIU/mL by 10 weeks of gestation.

Answer 16

plateaus at 100,000

by 10th week of pregnancy.

Question 17

Decreasing hCG values suggest a failing pregnancy and may be used to monitor spontaneous resolution, but this decrease should not be considered diagnostic. Approximately 95% of women with a spontaneous early pregnancy loss will have a decrease in hCG concentration of 21–35% in 2 days depending on initial hCG levels (34). A woman with decreasing hCG values and a possible ectopic pregnancy should be monitored until nonpregnant levels are reached because rupture of an ectopic pregnancy can occur while levels are decreasing or are very low.

Answer 17

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Question 18

When the possibility of a progressing intrauterine gestation has been reasonably excluded, uterine aspiration can help to distinguish early intrauterine pregnancy loss from ectopic pregnancy by identifying the presence or absence of intrauterine chorionic villi.

Answer 18

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Question 19

. Large decreases in hCG levels are more consistent with failed intrauterine pregnancy than ectopic pregnancy. In two small series of women undergoing uterine aspiration for pregnancy of unknown location, nearly all women with a decrease in hCG levels of 50% or greater within 12–24 hours after aspiration had failed intrauterine pregnancies

Answer 19

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decrease in hcg of 50% or greater within 12-24 hours of aspiration

Question 20

close follow-up with serial hCG measurement, with consideration of treatment for ectopic pregnancy based on clinical factors such as plateau or increase in hCG, development of symptoms, or high clinical suspicion or strong risk factors for ectopic pregnancy (29, 40, 41).

Answer 20

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Question 21

The choice of performing a uterine aspiration before treatment with methotrexate should be guided by a discussion with the patient regarding the benefits and risks, including the risk of teratogenicity in the case of an ongoing intrauterine pregnancy and exposure to methotrexate.

Answer 21

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Question 22

Methotrexate is a folate antagonist that binds to the catalytic site of dihydrofolate reductase, which interrupts the synthesis of purine nucleotides and the amino acids serine and methionine, thereby inhibiting DNA synthesis and repair and cell replication.

Answer 22

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Question 23

In addition, methotrexate administration should be avoided in patients with clinically significant elevations in serum creatinine, liver transaminases, or bone marrow dysfunction indicated by significant anemia, leukopenia, or thrombocytopenia.

Answer 23

avoid in:

• significant elevations in serum creatinine
• liver transaminases
• bone marrow dysfunction indicated by ( severe anemia, leukopenia, or thrombocytopenia)

Question 24

a high initial hCG level is considered a relative contraindication. Systematic review evidence shows a failure rate of 14.3% or higher with methotrexate when pretreatment hCG levels are higher than 5,000 mIU/mL compared with a 3.7% failure rate for hCG levels less than 5,000 mIU/mL

Answer 24

failure rate of 14% if hcg >5,000

Question 25

Because methotrexate affects rapidly dividing tissues, gastrointestinal problems (eg, nausea, vomiting, and stomatitis) are the most common adverse effects after multiple doses. Vaginal spotting is expected. It is not unusual for women treated with methotrexate to experience abdominal pain 2–3 days after administration, presumably from the cytotoxic effect of the drug on the trophoblastic tissue. In the absence of signs and symptoms of overt tubal rupture and significant hemoperitoneum, abdominal pain usually can be managed expectantly by monitoring a woman’s hemoglobin level and intraperitoneal fluid amount with transvaginal ultrasonography.

Answer 25

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Question 26

atients should be advised to avoid folic acid supplements, foods that contain folic acid, and nonsteroidal antiinflammatory drugs during therapy because these products may decrease the efficacy of methotrexate.

Answer 26

-folic acid
-nsaids
-foods with folic acid
should be avoided because may decrease efficacy of methotrexate

Question 27

__ also should be avoided during treatment to limit the risk of methotrexate dermatitis

Answer 27

Sunlight exposure

Question 28

The product labeling approved by the U.S. Food and Drug Administration recommends that women avoid pregnancy during treatment and for at least one ovulatory cycle after methotrexate therapy

Answer 28

recommended that women delay pregnancy for at least 3 months after last dose of methotrexate

Question 29

Surgical management of ectopic pregnancy is required when a patient is exhibiting any of the following: hemodynamic instability, symptoms of an ongoing ruptured ectopic mass (such as pelvic pain), or signs of intraperitoneal bleeding.

Answer 29

hemodynamic instability
symptoms of ongoin ruptured ectopic mass (pelvic pain)
or intraperitoneal bleeding

Question 30

Surgical management generally is performed using laparoscopic salpingectomy (removal of part or all of the affected fallopian tube) or laparoscopic salpingostomy

Answer 30

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Question 31

Surgical management of

Answer 31

ectopic pregnancy is required when a patient is exhibiting any of the following: hemodynamic instability, symptoms of an ongoing ruptured ectopic mass (such as pelvic pain), or signs of intraperitoneal bleeding.

Question 32

If the concept of the hCG discriminatory level is to be used as a diagnostic aid in women at risk of ectopic pregnancy, the value should be conservatively high (eg, as high as 3,500 mIU/mL) to avoid the potential for misdiagnosis and possible interruption of an intrauterine pregnancy that a woman hopes to continue.

Answer 32

3500

Question 33

Failure of the hCG level to decrease by at least 15% from day 4 to day 7 after methotrexate administration is associated with a high risk of treatment failure and requires additional methotrexate administration (in the case of the single-dose or two-dose regimen) or surgical intervention.

Answer 33

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