Ectopic pregnancy

Question 1

Define ectopic pregnancy

Answer 1

Pregnancy implanted outside the uterus

Question 2

What is the most common site for an ectopic pregnancy insertion?

Answer 2

Ampulla of the fallopian tubes.

Question 3

What are the key risk factors for an ectopic pregnancy?

Answer 3

Ectopic before
Coils - IUDs
Tissue -> endometriosis or uterine scarring
Older age
Pelvic Inflammatory disease/ POP
Infertility - assisted such as IVF
Chlamydia
Smoking

Question 4

At what gestation does an ectopic pregnancy commonly present?

Answer 4

6-8weeks

Question 5

What are the classical presenting features of an ectopic pregnancy?

Answer 5

Missed period
Constant lower abdominal pain in the R/L iliac fossa
Vaginal bleeding
Lower abdo/pelvic tenderness
Cervical motion tenderness

Question 6

What can indicate that an ectopic pregnancy has ruptured?

Answer 6

Generally unwell - dizziness, syncope, Haemo unstable

Shoulder tip pain due to peritonitis (Kehrs sign??)

Question 7

What is the gold standard investigation for identifying an ectopic pregnancy?

Answer 7

Transvaginal ultrasound
May contain yolk sac or fetal pole
Or may be empty - blob sign, bagel sign, tubal ring sign

Question 8

What is meant by a pregnancy of unknown location?

Answer 8

Positive pregnancy test with no signs of pregnancy on US
hCG must be repeated after 48hrs -> in uterine pregnancy expect to double every 48hrs, not true in ectopic -> clinical range >63% uterine.

Question 9

How soon after a miscarriage should a pregnancy test take place?

Answer 9

After 2 weeks.
This confirms loss of foetus.

Question 10

What are the three options for terminating an ectopic pregnancy?

Answer 10

Expectant management (await natural termination)
Medical (methotrexate)
Surgical (salpingectomy or salpingotomy)

Question 11

What criteria must be met for an expectant management of an ectopic pregnancy?

Answer 11

Follow up available
Unruptured
Mass <35mm
No Heart beat
No significant pain
HCG <1000

Question 12

What criteria must be met for medical management of an ectopic pregnancy?

Answer 12

Same as expectant plus
HCG <1,500
Confirmed absence of intrauterine pregnancy.
Confirm happy to attend follow up.

Question 13

What medication can be given to treat ectopic pregnancy?

Answer 13

IM methotrexate into gluteal muscles

Question 14

What counselling must be given to a patient taking methotrexate for an ectopic pregnancy?

Answer 14

Not to conceive within 6m as highly tetrogenic

Side effects:
N&V
Vaginal bleeding
Abdo pain
Stomatitis

Question 15

When might surgical management be used for an ectopic?

Answer 15

HCG >5000
Or adenexal mass >35mm
Visible heart beat
Pain
Can be ruptured

Question 16

What are the different surgical options for ectopic pregnancy?
Why might each option be chosen?

Answer 16

Salpingotomy -> if high risk infertility, although inc risk of procedure failure, (still got both tubes)

Salpingetomy -> less fertility concerned, more likely effective

Both must be followed with Anti-D if rhesus neg mother

Question 17

What is the pathology underlying ectopic pregnancy?

Answer 17

Fertilised ovum is unable to reach the endometrial lining due to impaired tubal transport or abnormal emrbyo-tubal interaction.

May be due to excess inflammation, loss of cilia in tubes or loss of singalling molcules.

Question 18

What are some signs of peritoneal bleeding?

Answer 18

Shoulder tip pain
Pain on defectation/tenesmus due to blood in pouch of douglas
Bruising on abdomen

Question 19

What are some potential complications of an ectopic pregnancy?

Answer 19

Tubal rupture -> intraperitoneal haemorrhage at 6-10w

Haemoperitoneum -> from trophoblast invasion.

Question 20

What are some potential complications of the treatment of an ectopic pregnancy?

Answer 20

Persistent trophoblastic tissue -> infection/abscess
Damage to reproductive organs
Psychological distress
Rh sensitization

Question 21

What is the difference between an ectopic pregnancy and a pregnancy of unknown location?

Answer 21

PUL = positive pregnancy test but neither an intrauterine or an ectopic pregnancy can be identified on an initial ultrasound scan

Question 22

How should bHCG be interpreted in relation to an ectopic pregnancy?

Answer 22

If fails to double in 48hrs suggests a non-viable or ectopic.