Ectopic pregnancy

Question 1

Ectopic pregnancy - definition

Answer 1

Implantation of fertilised ovum (blastocyst in tissue other than endometrium of uterine cavity)

Question 2

Ectopic pregnancy - epi

Answer 2

1. Principal cause of maternal death in first trimester
2. Incidence in general population = 1:200
3. With IVF, there is a risk of ectopic and heterotopic pregnancy (coexisting intrauterine and ectopic pregnancies) in 1.4% of pregnant cycles

Question 3

Ectopic pregnancy - sites

Answer 3

1. Fallopian tube (most common site, 97%)

Other sites

2. Ovary
3. Cervix
4. Broad ligament
5. CS scar or peritoneal cavity

Question 4

Ectopic pregnancy - symptoms

Answer 4

1. Often asymptomatic (e.g. unsure dates)
2. Amenorrhoea (usually 6-8 weeks)
3. Pain (lower abdominal, often mild and vague, classically unilateral; may have shoulder tip pain if diaphragmatic irritation due to haemoperitoneum)
4. Vaginal bleeding (usually small amount, often brown)
5. Dizziness and light-headedness, collapse

Question 5

Ectopic pregnancy - signs

Answer 5

1. Often have no specific signs
2. Uterus usually normal size
3. Cervical excitation and adnexal tenderness occasionally
4. Adnexal mass very rarely
5. Peritonism (due to intra-abdominal blood if ectopic ruptured).

Question 6

Ectopic pregnancy - ix

Answer 6

1. TVS/USS: to establish the location of the pregnancy, the presence of adnexal masses or free fluid: a good EPAU will positively identify EP on TVS in 90% of cases, rather than the absence of an intrauterine gestation.
2. Serum hCG. Repeat 48h later. The rate of rise is important. A rise of ≥66% suggests an IUP; a suboptimal rise is suspicious, but not diagnostic of an EP.
3. Serum progesterone: helpful to distinguish whether a pregnancy is failing:

Question 7

Ectopic pregnancy - risk factors (7)

Answer 7

1. Hx infertility or assisted conception, especially IVF
2. Hx PID
3. Endometriosis
4. Pelvic or tubal surgery
5. Previous ectopic
6. IUD in situ
7. Smoking

Question 8

Ectopic pregnancy - mx

Answer 8

1. Expectant management in selected cases:
   - Low beta hCG (1000-1500IU/mL
2. Most common surgical approach = laparoscopy. Ruptured ectopic + relative haemodynamic stability. Associated with less blood loss, shorter hospital stay, lower analgesic requirements and quicker post-operative recovery compared with laparotomy. Laparoscopic salpingectomy or salpingostomy can be performed. No difference in subsequent IUP rates, but salpingectomy associated with lower rates of recurrent EP. Salpingotomy if contralateral tubal disease
3. In haemodynamically unstable pts, laparotomy more appropriate bc it is quicker
4. Anti-D in Rh -ve pts

Question 9

Methotrexate - side effects (3)

Answer 9

1. Conjunctivitis
2. Stomatitis
3. Gastrointestinal upset

Question 10

Tx of haemodynamically unstable pt

Answer 10

Resuscitation

1. Two large bore IV lines and IV fluids (colloids or crystalloids)
2. Cross-match 6U blood
3. Call senior help and anaesthetic assistance urgently

Surgery (once pt has been resuscitated)

4. Laparotomy
5. With salpingectomy