Ectopic Pregnancy

Question 1

What is the ectopic pregnancy?

Answer 1

Gynaecological emergency where a fertilised ovum that has implanted outside the endometrial cavity, usually in the fallopian tubes

Question 2

What is the most common site of ectopic pregnancy?

Answer 2

Ampulla and isthmus

Question 3

What is the typical onset of ectopic pregnancy?

Answer 3

6-8th week after last period with bleeding. First symptom is abdominal pain due to tubual spasm and mauy be constant and unilateral

Question 4

What is a classic history of ectopic pregnancy?

Answer 4

female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding.

Pain on defaecation/urination and breast tenderness.

Question 5

Where does pain refer in ectopic pregnancy?

Answer 5

Abdomianl pain refers to shoulder tip Due to irritation Of Diaphragm and supraclavicular nerves of C3-C5 dermatome

Pain on defecation and urination

Question 6

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

Answer 6

*Previous sti OR IUD
*Pelvic Surgery
*Assisted Preproduction
*Endometriosis
*Pelvic inflammatory disease
*Previous ectopic pregnancy
*Previous tubal surgery

Question 7

What are the general features of ectopic pregnancy?

Question 8

What are indicators of rupture of ectopic pregnancy?

Answer 8

Pallor
Increased CRT
Tachycardia
Hypotension

Question 9

What are the examination findings in ectopic pregnancy?

Answer 9

Abdominal tenderness
Cervical excitation motion tenderness on biannual examination
Shoulder tip pain
Signs of haemodynamically instability

Question 10

What examination should not be done in ectopic pregnancy?

Answer 10

Adnexal mass for growth near the uterus as there is ris of pregnancy rupture

Question 11

Which HCG level indicates ectopic pregnancy?

Answer 11

HCG over 1,500, even with no intrauterine pregnancy on transvaginal ultrasound

Diagnostic laparoscopy should be offerred

Question 12

What investigation is reccomended for ectopic pregnancy?

Answer 12

Transvaginal ultrasound to locate the pregnancy

Question 13

What size ectopic pregnancy affects management?

Answer 13

35mm

Question 14

What medication increases risk of ectopic pregnancy?

Answer 14

Progesterone oral contraception due to fallopian tube ciliary dysmotility

IUD or IUS

Question 15

What causes vaginal bleeding in ectopic pregnancy?

Answer 15

Low b-hCG levels to maintain uterine lining resulting in breakdown of uterine cavity. The bleeding is brown in colour

Question 16

What is cervical excitation?

Answer 16

AKA chandelier sign, with pain on bimannual pelvic exam, indicating periontela inflammation

Question 17

What is the most dangerous location f ectopic pregnancy?

Answer 17

Isthmus, as the narrow part of the fallopian tube near the uterus) because the thin muscular wall and rich blood supply make it prone to early, catastrophic rupture, leading to severe internal bleeding, shock, and high maternal mortality

Question 18

what is the most common location of ectopic pregnancy?

Answer 18

Tubal, in the ampulla

Question 19

What is a tubal abortion?

Answer 19

type of ectopic pregnancy where a fertilized egg implants in the fallopian tube and is then spontaneously expelled through the end of the tube (the fimbriae) into the abdominal cavity

Question 20

What is a tubal absorption?

Answer 20

if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed

Question 21

What is the common resolution of ectopic pregnancy?

Answer 21

• tubal abortion
• tubal absorption
• tubal rupture

Question 22

What is an important intial investigation for ectopic pregnancy?

Answer 22

Urine B-HCG

Question 23

What is pregnancy of unknown location?

Answer 23

If a pregnancy cannot be identified on ultrasound scan (but β-HCG is positive

Question 24

What to consider for B-HCG level below 1500 in stable patient with expected viablepregnancy?

Answer 24

HCG should double every 48 hours

Question 25

What to consider for B-HCG level below 1500 in stable patient with expected miscarriage?

Answer 25

In a miscarriage, HCG level would be expected to halve every 48 hours

Question 26

What are the 3 types of management for ectopic pregnancy?

Answer 26

*Expectant management *Surgical management *Medical management

Question 27

What is expectant management?

Answer 27

involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.

Question 28

When is expectant management performed?

Answer 28

Size less than 35mm, unruptured pregnancy, asymptomatic. HCG will be over 1,000 and compatible if another intrauterine pregnancy is present

Question 29

What is medical management?

Answer 29

Adminstering methotrexate to terminate non-viable pregnancy by acting as folate antagonist for promoting tissue to be absorbed and preserve fallopian tube.

Question 30

When is medical management done in ectopic pregnancy?

Answer 30

Size less than 35mm, for unruptured pregnancy and no foetal heartbeat with no significant pan. It is not suitable for intrauterine pregnancy

Question 31

When is surgical management done for ectopic pregnancy?

Answer 31

Ruptured ectopic pregnancy, with signficant pain, size over 35mm and resent foetal heartbeat. HCG will be over 5,000 and is compatible with a pre-existing intrauterine pregnancy

Question 32

What is the first line surgical management?

Answer 32

Salpingectomy is first-line for women with no other risk factors for infertility, with removal for both fallopian tubes and often performed laparoscopically

Question 33

What is the surgical management for ectopic pregnancy in women with no other risk factors?

Answer 33

Salpingotomy, a fertility preserving procedure by making small incision in fallopians tube to remove pregnancy and leave tube intact. However there is risk of future ectopic pregnancy so requires further treatment with methotrexate

Question 34

What is the criteria for methotrexate treatment in ectopic pregnancy?

Answer 34

Unruptured ectopic pregnancy measuring below 35mm and with no visible heartbeat - Ability to attend follow-up - Adherence to avoiding pregnancy for a period following treatment - No intrauterine pregnancy (confirmed on an ultrasound scan

Question 35

When is surgical management indicated?

Answer 35

Patient is unable to attend follow-up - Serum hCG level of 5000 IU/L or higher - Adnexal mass of 35mm or greater - Foetal heartbeat is visible on ultrasound scan - Patient is in significant pain - Patient is haemodynamically unstable

Question 36

What procedures can indicate necessity of salpingomyotomy?

Answer 36

due to previous PID or ectopic, or past removal of a fallopian tube

Question 37

What is a risk with salpinomyotomy?

Answer 37

not all the tissue may have been removed, and so serial serum b-hCG measurements are performed to exclude any remaining trophoblastic tissue within the fallopian tube

Question 38

When is ectopic pregnancy unlikely?

Answer 38

Second trimester as it would have been confirmed at first ultrasound on booking visit

Question 39

How to manage ectopic pregnancy,

Answer 39

Salpingectomy -> salpingectomy should be considered for women with risk factors for infertility such as contralateral tube damage

Question 40

What indicates

Question 41

What history is indicated for surgical rather than medical management of ectopic pregnancy?

Answer 41

symptomatic and has a foetal heartbeat and is therefore at risk of ectopic rupturing, which could be life-threatening

Question 42

What are the indications for expectant management of ectopic pregnancy?

Answer 42

An unruptured embryo 2) <35mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <1,000IU/L and declining

Question 43

What is a social risk factor for ectopic pregnancy?

Answer 43

Chlamydia

Question 44

What procedures are not reccomended in ectopic pregnancy!

Answer 44

Intrauterine procedures like: Manual vaccum aspiration Cervical dilation and evacuation with forceps Cervical dilation and curettage

Question 45

How to manage ectopic pregnancy where saplingotomy is unsuccessful?

Answer 45

Methotrexate with or without salpingectomy

Question 46

Which HCG level indicates surgical amangement of ectopic pregnancy.

Answer 46

serum B-hCG >5,000IU/L should be managed surgically

Question 47

How to manage ectopic pregnancy with foetal heartbeat.

Answer 47

Surgical management

Question 48

How does patient symptoms change management of ectopic pregnancy?

Answer 48

Any symptoms like abdominal pain requires surgical management.

Question 49

When to do expectant management for ectopic pregnancy?

Answer 49

1) An unruptured embryo 2) <35mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <1,000IU/L and declining

Question 50

What foetal aspect is an indication for surgical management of ectopic pregnancy?

Answer 50

Presence of a foetal heartbeat

Question 51

Which location for ectopic pregnancy has a high risk of rupture!

Answer 51

Isthmus due to being the narrowest part

Question 52

What causes snowstorm appearance on ultrasound?

Answer 52

Molar pregnancy Gestational trophoblastic disease, with very high β-hCG levels, uterine enlargement, or abnormal bleeding.

Question 53

What causes ultrasound to show empty intrauterine embryonic sac?

Answer 53

Anembryonic pregnancy when a gestational sac develops, but the embryo fails to form or stops developing early

Question 54

What indicates early anembryonic pregnsncy?

Answer 54

If no intrauterine sac is visualised by the time hCG exceeds 1500–2000 IU/L, and no ectopic pregnancy is seen, this may reflect an early anembryonic pregnancy

Question 55

What blood markers show anembryonic pregnancy?

Answer 55

Initially, the β-hCG may rise normally or suboptimally, and the uterus may appear empty or show a sac with no yolk sac or embryo

Question 56

What HCG level indicates molar pregnancy?

Answer 56

β-hCG readings of 100,000 mIU/ml and above

Question 57

What HCG level indicates ectopic pregnancy?

Answer 57

If it is more than 1500 mIU/ml, the pregnancy should be treated as ectopic.

Question 58

What does it mean if two HCG is taken and second reading is less than half of the first reading?

Answer 58

Miscarriage

Question 59

When to do medical amangement of ectopic?

Answer 59

IM methotrexate if: *haemodynamically stable *BHCG less than 5000 *Adnexal mass less than 35mm *No intrauterine pregnancy

Question 60

How to manage ectopic pregnancy with mild pain?

Answer 60

Medical amangement

Question 61

What is a non-textbook anecdotal presentation of ectopic?

Answer 61

Rectal pain and urge to defaecate