A - MSRA Gynaecology [8] > [14] Ectopic Pregnancy > Flashcards

[14] Ectopic Pregnancy Flashcards

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1
Q

What is an ectopic pregnancy?

A

Any pregnancy which is implanted at a site outside of the uterine cavity

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2
Q

What are the most common sites of implantation in ectopic pregnancy?

A

Ampulla and isthmus of the fallopian tubes

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3
Q

What are the less common sites of implantation in ectopic pregnancy?

A
  • Ovaries
  • Cervix
  • Peritoneal cavity
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4
Q

What is the rate of ectopic pregnancy in the UK?

A

11 in 1000 pregnancies

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5
Q

What is the mortality rate in ectopic pregnancy?

A

~ 0.2 per 100

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6
Q

What proportion of ectopic pregnancy mortalities are due to substandard care?

A

2/3

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7
Q

What proportion of women with ectopic pregnancy do not have any known risk factors?

A

1/3

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8
Q

What are some known risk factors for ectopic pregnancy?

A
  • Past medical history factors
  • Contraceptive factors
  • Iatrogenic factors
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9
Q

What are the past medical history risk factors for ectopic pregnancy?

A
  • Previous ectopic pregnancy
  • PID
  • Endometriosis
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10
Q

What are the contraceptive risk factors for ectopic pregnancy?

A
  • IUD or IUS
  • Progesterone oral contraceptive or implant
  • Tubal ligation or occlusion
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11
Q

Why can PID and endometriosis lead to ectopic pregnancy?

A

Due to adhesion formation

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12
Q

Why can progesterone oral contraceptive or implant lead to ectopic pregnancy?

A
  • Due to fallopian tube ciliary dysmotility
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13
Q

What are the iatrogenic risk factors for ectopic pregnancy?

A
  • Pelvic surgery - especially tubal

- Assisted reproduction

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14
Q

What is an example of a tubal surgery that can lead to higher risk of ectopic pregnancy?

A

Reversal of sterilisation

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15
Q

What are the most common symptoms of ectopic pregnancy?

A
  • Abdominal pain
  • Pelvic pain
  • Amenorrhoea or missed period
  • Vaginal bleeding with or without clots
  • Vaginal discharge
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16
Q

How does discharge in ectopic pregnancy appear?

A

Brown, and like prune juice

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17
Q

What causes the brown discharge in ectopic pregnancy?

A

The decidua breaking down

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18
Q

What are some other symptoms of ectopic pregnancy?

A
  • Dizziness, fainting or syncope
  • Breast tenderness
  • Shoulder tip pain
  • Urinary symptoms
  • GI symptoms such as diarrhoea and/or vomiting
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19
Q

What may be seen on examination in ectopic pregnancy?

A
  • Localised abdominal tenderness

- Vaginal examination reveals cervical excitation and/or adnexal tenderness

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20
Q

What may be seen in the patient if the ectopic pregnancy has ruptured?

A

Signs of haemodynamic instability and/or signs of peritonitis

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21
Q

What are some signs of haemodynamic instability?

A
  • Pallor
  • Increased CRT
  • Tachycardia
  • Hypotension
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22
Q

What are signs of peritonitis?

A
  • Rebound tenderness

- Guarding

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23
Q

Why may the amount of vaginal bleeding be misleading in ruptured ectopic pregnancy?

A

Blood will mostly enter the pelvis and so vaginal bleeding may be minimal

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24
Q

What are the differentials for ectopic pregnancy?

A
  • Miscarriage
  • Ovarian cyst accident
  • Acute PID
  • Appendicitis
  • Diverticulitis
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25
What are the first line tests for suspected ectopic pregnancy?
- Urine pregnancy test | - Pelvic USS
26
Which investigation is most important in first assessing ectopic pregnancy?
Urine pregnancy test
27
When should a pelvic USS be performed in suspected ectopic pregnancy?
If pregnancy test is positive
28
What can pelvic USS show in suspected ectopic pregnancy?
Presence or absence of intrauterine pregnancy
29
What should be offered if transabdominal USS cannot identify an intrauterine pregnancy?
Transvaginal USS
30
What is the term used for a positive urine beta-HCG but not identifiable pregnancy on USS?
Pregnancy of unknown location
31
What are the 3 possible differentials for pregnancy of unknown location?
- Very early intrauterine pregnancy - Miscarriage - Ectopic pregnancy
32
What additional test should be taken in pregnancy of unknown location?
Serum beta-HCG
33
What is assumed if serum beta-HCG for pregnancy of unknown location is >1500 iU
Ectopic pregnancy until proven otherwise
34
What should be offered if serum beta-HCG suggests ectopic pregnancy?
Diagnostic laparoscopy
35
What should be done if initial serum beta-HCG for pregnancy of unknown location is <1500 iU?
A further serum beta-HCG 48 hours later
36
What would happen to the serum beta-HCG level over 48 hours if there is a viable pregnancy?
It should double
37
What would happen to the serum beta-HCG level over 48 hours if there is a miscarriage?
It should halve
38
When can an ectopic pregnancy not be excluded based on serial serum beta-HCG result?
If there is less than a double or half in the level over 48 hours
39
Where should any patient with a suspected ectopic pregnancy be managed?
In hospital
40
What may be needed if the patient is systemically unwell?
A-E approach to resuscitation possible including blood products
41
What are the three types of definitive management for ectopic pregnancy?
- Conservative - Medical - Surgical
42
What does conservative management of ectopic pregnancy involve?
Watchful waiting of the stable patient while allowing the ectopic to resolve naturally
43
Is conservative management of ectopic pregnancy first line?
No, it is only suitable for a small number of patients and should be discussed at a senior level
44
What should be performed to monitor progress of conservative management of ectopic pregnancy?
Serum beta-HCG every 48 hours to ensure it is falling by at least 50% every 48 hours
45
At what level is beta-HCG satisfactory in conservative management of ectopic pregnancy?
<5mlU/ml
46
Who can conservative management for ectopic pregnancy be offered to?
- Unlikely to rupture - Stable - Well controlled pain - Low baseline beta-HCG - Small, unruptured ectopic on USS
47
What advice should be given to patients having conservative management of ectopic pregnancy?
- 24/7 access to gynae services | - Informed of symptoms of rupture
48
What are the advantages of conservative management of ectopic pregnancy?
- Avoids risks of medical and surgical management | - Can be done at home
49
What are the disadvantages of conservative management of ectopic pregnancy?
- Failure or complications may necessitate need for surgery or medical management
50
What percentage of patients receiving conservative ectopic pregnancy management require surgical or medical intervention?
25%
51
What is the medical management of ectopic pregnancy?
IM methotrexate
52
How does methotrexate work to treat ectopic pregnancy?
It is an anti-folate cytotoxic agent that disrupts folate dependent cell division of the developing fetus
53
What monitoring should a patient on methotrexate for ectopic pregnancy receive?
Regular serum beta-HCG to ensure levels decline
54
What is done if beta-HCG levels don't decline after initial dose of IM methotrexate in ectopic pregnancy?
Administer another
55
Who can receive methotrexate to treat ectopic pregnancy?
- Stable patients - Well controlled pain - Beta-HCG <1500iU/ml - Ectopic pregnancy unruptured without visible heartbeat
56
What advice should women undergoing medical management of ectopic pregnancy be given?
- 24/7 access to gynae services | - Symptoms of rupture
57
What are the advantages of medical management of ectopic pregnancy?
- Avoids complications of surgery | - Patient can be at home after injection
58
What are the disadvantages of medical management ectopic pregnancy?
- Potential side-effects of methotrexate - Teratogenic and so patients should use contraception for 3-6 months after - Treatment can fail - need surgery
59
What are the potential side-effects of methotrexate?
- Abdominal pain - Myelosuppression - Renal dysfunction - Hepatitis
60
What is involved in surgical management of ectopic pregnancy?
Surgical removal of the ectopic (this seems a bit too obvious but I'll leave it in)
61
What is the usual procedure for a tubal ectopic?
Laparoscopic salpingectomy
62
What happens in a laparoscopic salpingectomy for tubal ectopic?
Removal of the tube the fetus is implanted in
63
If there is damage to the contralateral tube what alternative procedure can be considered to preserve fertility?
Salpingotomy
64
What follow-up is require in a salpingotomy for ectopic pregnancy?
HCG testing until <5iU
65
What happens to the risk of future ectopic pregnancy in the tube that underwent salpingotomy?
Increase
66
When is surgical management of ectopic pregnancy considered?
- Severe pain - Serum beta-hCG >5000mlU/ml - Adnexal mass >34mm - Visible fetal heart beat
67
What are the advantages of surgical management of ectopic pregnancy?
- Reassurance of definitive treatment | - High success rate
68
What are the disadvantages of surgical management of ectopic pregnancy?
- GA risk - Risk of damaging neighbouring structures - Risk of treatment failure with salpingotomy
69
What structures are at risk in surgical management of ectopic pregnancy?
- Bladder - Bowel - Ureters - DVT/PE - Haemorrhage - Infection
70
Why may a salpingotomy fail at treating ectopic pregnancy?
Some pregnancy may remain
71
What should all Rh -ve women receive before surgical management of ectopic pregnancy?
Anti-D prophylaxis
72
What are the potential complications of ectopic pregnancy?
- Tubal or uterine rupture - Massive haemorrhage - Shock - DIC - Death
A - MSRA Gynaecology [8]
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