Flashcards in Ectopic Pregnancy Deck (72)
What is an ectopic pregnancy?
Any pregnancy which is implanted at a site outside of the uterine cavity
What are the most common sites of implantation in ectopic pregnancy?
Ampulla and isthmus of the fallopian tubes
What are the less common sites of implantation in ectopic pregnancy?
- Peritoneal cavity
What is the rate of ectopic pregnancy in the UK?
11 in 1000 pregnancies
What is the mortality rate in ectopic pregnancy?
~ 0.2 per 100
What proportion of ectopic pregnancy mortalities are due to substandard care?
What proportion of women with ectopic pregnancy do not have any known risk factors?
What are some known risk factors for ectopic pregnancy?
- Past medical history factors
- Contraceptive factors
- Iatrogenic factors
What are the past medical history risk factors for ectopic pregnancy?
- Previous ectopic pregnancy
What are the contraceptive risk factors for ectopic pregnancy?
- IUD or IUS
- Progesterone oral contraceptive or implant
- Tubal ligation or occlusion
Why can PID and endometriosis lead to ectopic pregnancy?
Due to adhesion formation
Why can progesterone oral contraceptive or implant lead to ectopic pregnancy?
- Due to fallopian tube ciliary dysmotility
What are the iatrogenic risk factors for ectopic pregnancy?
- Pelvic surgery - especially tubal
- Assisted reproduction
What is an example of a tubal surgery that can lead to higher risk of ectopic pregnancy?
Reversal of sterilisation
What are the most common symptoms of ectopic pregnancy?
- Abdominal pain
- Pelvic pain
- Amenorrhoea or missed period
- Vaginal bleeding with or without clots
- Vaginal discharge
How does discharge in ectopic pregnancy appear?
Brown, and like prune juice
What causes the brown discharge in ectopic pregnancy?
The decidua breaking down
What are some other symptoms of ectopic pregnancy?
- Dizziness, fainting or syncope
- Breast tenderness
- Shoulder tip pain
- Urinary symptoms
- GI symptoms such as diarrhoea and/or vomiting
What may be seen on examination in ectopic pregnancy?
- Localised abdominal tenderness
- Vaginal examination reveals cervical excitation and/or adnexal tenderness
What may be seen in the patient if the ectopic pregnancy has ruptured?
Signs of haemodynamic instability and/or signs of peritonitis
What are some signs of haemodynamic instability?
- Increased CRT
What are signs of peritonitis?
- Rebound tenderness
Why may the amount of vaginal bleeding be misleading in ruptured ectopic pregnancy?
Blood will mostly enter the pelvis and so vaginal bleeding may be minimal
What are the differentials for ectopic pregnancy?
- Ovarian cyst accident
- Acute PID
What are the first line tests for suspected ectopic pregnancy?
- Urine pregnancy test
- Pelvic USS
Which investigation is most important in first assessing ectopic pregnancy?
Urine pregnancy test
When should a pelvic USS be performed in suspected ectopic pregnancy?
If pregnancy test is positive
What can pelvic USS show in suspected ectopic pregnancy?
Presence or absence of intrauterine pregnancy
What should be offered if transabdominal USS cannot identify an intrauterine pregnancy?
What is the term used for a positive urine beta-HCG but not identifiable pregnancy on USS?
Pregnancy of unknown location
What are the 3 possible differentials for pregnancy of unknown location?
- Very early intrauterine pregnancy
- Ectopic pregnancy
What additional test should be taken in pregnancy of unknown location?
What is assumed if serum beta-HCG for pregnancy of unknown location is >1500 iU
Ectopic pregnancy until proven otherwise
What should be offered if serum beta-HCG suggests ectopic pregnancy?
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
What would happen to the serum beta-HCG level over 48 hours if there is a viable pregnancy?
It should double
What would happen to the serum beta-HCG level over 48 hours if there is a miscarriage?
It should halve
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
Where should any patient with a suspected ectopic pregnancy be managed?
What may be needed if the patient is systemically unwell?
A-E approach to resuscitation possible including blood products
What are the three types of definitive management for ectopic pregnancy?
What does conservative management of ectopic pregnancy involve?
Watchful waiting of the stable patient while allowing the ectopic to resolve naturally
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
What should be performed to monitor progress of conservative management of
Serum beta-HCG every 48 hours to ensure it is falling by at least 50% every 48 hours
At what level is beta-HCG satisfactory in conservative management of ectopic pregnancy?
Who can conservative management for ectopic pregnancy be offered to?
- Unlikely to rupture
- Well controlled pain
- Low baseline beta-HCG
- Small, unruptured ectopic on USS
What advice should be given to patients having conservative management of ectopic pregnancy?
- 24/7 access to gynae services
- Informed of symptoms of rupture
What are the advantages of conservative management of ectopic pregnancy?
- Avoids risks of medical and surgical management
- Can be done at home
What are the disadvantages of conservative management of ectopic pregnancy?
- Failure or complications may necessitate need for surgery or medical management
What percentage of patients receiving conservative ectopic pregnancy management require surgical or medical intervention?
What is the medical management of ectopic pregnancy?
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
What monitoring should a patient on methotrexate for ectopic pregnancy receive?
Regular serum beta-HCG to ensure levels decline
What is done if beta-HCG levels don't decline after initial dose of IM methotrexate in ectopic pregnancy?
Who can receive methotrexate to treat ectopic pregnancy?
- Stable patients
- Well controlled pain
- Beta-HCG <1500iU/ml
- Ectopic pregnancy unruptured without visible heartbeat
What advice should women undergoing medical management of ectopic pregnancy be given?
- 24/7 access to gynae services
- Symptoms of rupture
What are the advantages of medical management of ectopic pregnancy?
- Avoids complications of surgery
- Patient can be at home after injection
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
What are the potential side-effects of methotrexate?
- Abdominal pain
- Renal dysfunction
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)
What is the usual procedure for a tubal ectopic?
What happens in a laparoscopic salpingectomy for tubal ectopic?
Removal of the tube the fetus is implanted in
If there is damage to the contralateral tube what alternative procedure can be considered to preserve fertility?
What follow-up is require in a salpingotomy for ectopic pregnancy?
HCG testing until <5iU
What happens to the risk of future ectopic pregnancy in the tube that underwent salpingotomy?
When is surgical management of ectopic pregnancy considered?
- Severe pain
- Serum beta-hCG >5000mlU/ml
- Adnexal mass >34mm
- Visible fetal heart beat
What are the advantages of surgical management of ectopic pregnancy?
- Reassurance of definitive treatment
- High success rate
What are the disadvantages of surgical management of ectopic pregnancy?
- GA risk
- Risk of damaging neighbouring structures
- Risk of treatment failure with salpingotomy
What structures are at risk in surgical management of ectopic pregnancy?
Why may a salpingotomy fail at treating ectopic pregnancy?
Some pregnancy may remain
What should all Rh -ve women receive before surgical management of ectopic pregnancy?