Ectopic Pregnancy

Question 1

Where does tubal ectopic pregnancy most commonly occur

Answer 1

Ampulla

Question 2

Where does ligamentous ectopic pregnancy most commonly occur

Answer 2

Broad ligament

Question 3

Classic triad symptoms of ectopic pregnancy

Answer 3

1 amenorrhea
2 vag bleeding
3 abdo pain

Mostly asymptomatic.

Question 4

dx Of ectopic pregnancy

Answer 4

• B-hCG - compare 2 measurements 48h apart. ≤35% increase.
• u/s - empty uterus + cystic mass to exclude intrauterine pregnancy
  Uterine pregnancy should be visible on TV us when bhcg 1000 - 2000 and abdominal us at 6500.
• confirmed with distinct adnexal mass on either side of or in pouch of Douglas on ultrasound.

Must be < 20 weeks. > 20 weeks = advanced extra-uterine pregnancy

Question 5

Criteria for expectant rx for ectopic pregnancy (4)

Answer 5

• Unruptured
• b-hcg < 1000
• b- HCG decrease over 48h (follow up every 48 hours)
• clinically stable / asymptomatic / no haemodynamic compromise
• ectopic < 4cm at time of diagnosis

Only if very early asymptomaticwith possible ectopic or inconclusive ultrasound

Question 6

Which medical rx use for ectopic pregnancy

Answer 6

Methotrexate

Question 7

Name 7 criteria that must be met before initiating medical rx for ectopic pregnancy

Answer 7

• unruptured
• 100% certainty of location of pregnancy; no co existing intrauterine heterotopic pregnant
• B-HCG < 5000 mIU/ml ( > 2000 increase odds failure X4,5)
• No fetal cardiac activity on TV u/s
• Hemodynamically stable
• Sac < 4 cm
• No contraindications to methotrexate
• ability to follow up after rX with serial b-hcg measurements until undetectable levels

Question 8

When do surgical rx for ectopic pregnancy (5)

Answer 8

Majority of women when as stable as possible,but surgery part of resus.

•unruptured
• B-HCG >3000
• Fetal cardiac activity on u/s
Sac > 4 cm (AKA not fit for medical treatment)
Or
•ruptured

Question 9

Risk factors ectopic pregnancy? (7)

Answer 9

Embryonal factors

• chromosomal, structural abnormalities

Maternal factors

• History previous PID!
• endometriosis, congenital abnormalities of fallopian tube
• AMA
• cigarette smoking
• infertility, infertility treatment IVF
• previous ectopic
• previous tubal surgery eg salpingostomy (remove contents) or tubal re-anastomosis

IUD and progesterone only contraception: increased risk ectopic in event of contraceptive failure

Question 10

Symptoms and signs ruptured ectopic? (3)

Answer 10

• Worsened abdominal pain with blood in peritoneal cavity, peritonism/rebound tender
• ultrasound: free fluid in abdomen
• hypovolaemic shock

Question 11

Name the 3 treatment options for ectopic

Answer 11

Expectant

Medical
- methotrexate

Surgical (majority) (with or without medical adjuvant)
- laparoscopic preferred:
- access salpingectomy,
- partial salpingectomy
- salpingostomy
- laparotomy

Question 12

Methotrexate moa

Answer 12

Folic acid antagonist that interferes with DNA synthesis and cell proliferation
(Used for medical management ectopic)

Question 13

Methotrexate medical contraindications (8)

Answer 13

• Severe renal impairment
• severe hepatic impairment
• alcohol abuse
• blood dyscrasias eg blood cancer, anemia, haemophilia, clotting disorders
• bone marrow hypoplasia
• leukopenia
• immunodeficiency: tb, HIV esp uncontrolled
• oral ulcers, active gi ulcer disease

Question 14

Name 6 side effects methotrexate

Answer 14

Dose dependent toxicity

• Stomatitis
• conjunctivitis
• gastritis
• impaired liver function
• bone narrow depression
• photosensitivity

Question 15

When may medical management for ectopic be preferred to surgical? (3)

Answer 15

• Cervical ectopic
• cesearean scar ectopic
• already treated surgically with salpingostomy to lower risk persistent trophoblast activity

Question 16

Preferred surgical treatment ectopic pregnancy in women with normal contralateral fallopian tubes?

Answer 16

Salpingectomy or partial Salpingectomy

Question 17

Preferred surgical treatment ectopic pregnancy in women with absent / pathological contralateral fallopian tubes?

Answer 17

Salpingostomy

Offer methotrexate post op to avoid persistent trophoblast activity. Must follow up with bhcg weekly until undetectable

Question 18

Investigations for suspected ectopic? (6)

Answer 18

• Hb
• type /screen
• serum bhcg
• rhesus status
• Pretreatment evaluation for methotrexate: U+e, LFT
• ultrasound