Ectopic pregnancy

Question 1

Definition of ectopic pregnancy

Answer 1

• Implantation of an embryo outside the uterine cavity (1%)
• Most common site is the fallopian tube (95%)
• Implantation can also occur in the:
  
  • Cornu (where uterus and fallopian tubes meet)
  • Cervix
  • Ovary
  • Abdominal cavity
  • Previous caesarean scar

Question 2

Risk factors for ectopic pregnancy

Answer 2

Risk factors → tubal epithelial damage → impaired gamete transport and faulty implantation

• Previous ectopic pregnancy
• PID
• Tubal surgery (sterilisation/reversal)
• IUD
• Assisted conception
• Smoking

Question 3

Complications of ectopic pregnancy

Answer 3

• Tubal rupture
  
  • Intra-abdominal bleeding & shock
• Tubal infertility

Question 4

Clinical features

Answer 4

Symptoms

• Common
  
  • Lower abdominal / pelvic pain
  • Vaginal bleeding (brown)
• Uncommon
  
  • Syncope / collapse
  • Shoulder-tip pain (intraperitoneal blood loss)

Signs

• Tachycardia
• Hypotension
• Abdominal / rebound tenderness
• Cervical excitation
• Uterus smaller than expected gestation

Question 5

Differential diagnosis for ectopic pregnancy

Answer 5

Pain and bleeding in early pregnancy:

• Miscarriage
• Molar pregnancy
• Pregnancy-related degeneration of a fibroid
• Non-pregnancy related causes of bleeding in early pregnancy
  
  • Cervicitis
  • Cancer
  • Trauma
• Non-pregnancy-related causes of abdominal pain

Question 6

Investigations for ectopic pregnancy

Answer 6

• Pregnancy test (urine hCG)
• Ultrasound (transvaginal)
• Serial serum hCG (if uterus is empty)
  
  • > 1000 IU/ml should be visible if intrauterine
  • hCG rises/falls by 66% in 48h
  • Declining/plateauing suggests ectopic/non-viable intrauterine pregnancy
• Laparoscopy

Question 7

Management of ectopic pregnancy

Answer 7

• Emergency admission
• Watchful waiting
• Medical management
  
  • Methotrexate
• Surgical management (laparoscopic)
  
  • Salpingectomy (removal of fallopian tube)
  • Salpingostomy (incision into fallopian tube)