Ectopic pregnancy

Question 1

how common are ectopic pregnancies?

Answer 1

2% of all pregnancies

Question 2

what explains the rising incidence of ectopic pregnancies?

Answer 2

• rising incidence of PID
• IVF
• early diagnosis

Question 3

what is the most common cause of first trimester pregnancy related deaths? why?

Answer 3

ectopic pregnancy

(concealed, intraperitoneal) hemorrhage

Question 4

ectopic pregnancy is the most common cause of pregnancy related death during which trimester? what is the direct cause?

Answer 4

first

(concealed, intraperitoneal) hemorrhage

Question 5

black women are how many times more likely to have an ectopic pregnancy compared to white women?

Answer 5

5x

Question 6

what are the HIGH risk factors for ectopic pregnancy?

Answer 6

• prior ectopic
• prior tubal surgery (reversal, reconstruction)
• history of tubal ligation, especially cautery
• IUD

Question 7

what are the MODERATE risk factors for ectopic pregnancy?

Answer 7

• prior IUD
• infertility
• multiple sexual partners
• smoking

Question 8

what are the SLIGHT risk factors for ectopic pregnancy?

Answer 8

• IVF
• age over 35
• prior spontaneous abortion

Question 9

what is the presentation for ectopic pregnancy?

Answer 9

• first trimester bleeding
• abdominal / pelvic pain
• asymptomatic

Question 10

what test is used to diagnose ectopic pregnancy? what is “seen”?

Answer 10

ultrasound - no intrauterine pregnancy by trans-vaginal US at a time when you SHOULD seen something

Question 11

what lab test is used to help diagnose ectopic pregnancy? what is the level?

Answer 11

quantitative B-hCG: 1500-2000

Question 12

what test is generally required before any significant decisions are made about ectopic pregnancy?

Answer 12

quantitative B-hCG: 1500-2000

Question 13

BHCG levels rise rapidly in what trimester? how often do they double?

Answer 13

first

double every 48 hours

Question 14

when do BHCG levels plateau?

Answer 14

around 10 weeks

Question 15

progesterone levels under what value indicate that the pregnancy is NOT normal?

Answer 15

less than 5 ng/mL

Question 16

at what BHCG level will you see a gestational sac by abdominal probe US?

Answer 16

6000

Question 17

what is the discriminatory zone?

Answer 17

zone in which you should reasonably be able to determine if the pregnancy is normal or not

Question 18

at a BHCG level of 6000 what should you be able to see by abdominal US?

Answer 18

gestational sac

Question 19

what is the medical management for (unruptured) ectopic pregnancy in STABLE patients?

Answer 19

methotrexate

Question 20

what are the two surgical treatment options for ectopic pregnancy?

Answer 20

• salpingectomy

- salpingotomy

Question 21

what are the indications for methotrexate in (unruptured) ectopic pregnancy?

Answer 21

• hemodynamically stable
• non-laparoscopic diagnosis
• patient desires future fertility
• general anesthesia poses a risk
• patient able to comply with follow up
• no contraindications

Question 22

what are the absolute contraindications for methotrexate in (unruptured) ectopic pregnancy? IMPORTANT

Answer 22

• breastfeeding
• immune deficiency disorder
• chronic liver disease
• preexisting blood dyscrasias
• known sensitivity
• acute pulmonary disease
• peptic ulcer disease

Question 23

what are the RELATIVE contraindications for methotrexate in (unruptured) ectopic pregnancy?

Answer 23

• unruptured mass over 3.5 cm
• fetal cardiac activity seen
• quantitative BHCG greater than predetermined level (6k - 15k)

Question 24

BHCG levels should decline by what % following methotrexate administration?

Answer 24

15%

Question 25

what are the signs of methotrexate treatment failure for (unruptured) ectopic pregnancy?

Answer 25

- significantly worse abdominal pain - hemodynamic instability - BHCG not declining by 15% by day 7 - increase or plateau of BHCG after day 7

Question 26

is risk of repeat ectopic pregancy higher following a salpingotomy or salpingectomy?

Answer 26

salpingotomy

Question 27

what puts a woman at the highest risk for an ectopic pregnancy?

Answer 27

prior tubal surgery