Ectopic pregnancy

Question 1

Definition

Answer 1

When a fertilised ovum does not implant on the endometrial lining of the uterus, instead, extra-uterine sites:
- Fallopian tube (MC)
- Ovary
- Abdomen

Question 2

Where within the Fallopian tube does the ectopic implantation most commonly occur?

Answer 2

The ampulla

Question 3

What happens to the ectopic implantation?

Answer 3

Tubal mole: embryo and blood clot retained in tube, can become chronic ectopic pregnancy or absorbed.
Tubal abortion: more common with ampullary ectopic, may cause a pelvic haematocele, or diffuse intraperitoneal bleeding
Tubal rupture (least common): more common with an ectopic in the isthmus

Question 4

Aetiology

Answer 4

Unknown

Question 5

Epidemiology

Answer 5

Anatomical factors: can cause delayed passage of the ovum to the uterus
- PID (scarring and adhesions)
- Previous ectopic pregnancy
- Tubal surgery
- Endometriosis
Non-anatomical:
- IVF
- IUD
- Smoking
- Progesterone only pill
- Diethylstilbestrol: medication previously used during pregnancy to prevent miscarriage

Question 6

Signs

Answer 6

• Abdo tenderness (associated peritonism)
• Haemodynamic instability: suspect a ruptured ectopic
• Cervical excitation: AKA cervical motion tenderness
• Adnexal mass: DO NOT PALPATE
• Kehr’s sign: shoulder pain (red flaf for potential rupture)

Question 7

Symptoms

Answer 7

• Abdo pain: lower cramping, often constant and unilateral
• Vaginal bleeding: dark brown and often less than a usual period
• Amenorhhoea
• N+V
• Dizziness or syncope
• Symptoms of pregnancy e.g. breast tenderness

Question 8

Why do we not palpate an adnexal mass?

Answer 8

Risk of rupture

Question 9

Classic presentation

Answer 9

6-8 week Hx of amenorrhoea followed by
lower abdominal pain and vaginal.

Question 10

Diagnosis

Answer 10

Urine hCG (pregnancy test) = confirmation of pregnancy
FIRST LINE = Transvaginal USS to identify location of pregnancy by assessing for the presence of the foetal pole and heart beat
Serial serum B-hcg: 2 samples taken 48 hrs apart with rise of > 63% suggestive of ectopic pregnancy.

Question 11

Ruptured Treatment

Answer 11

ABCDE
FIRST LINE = Laproscopic salpingectomy
- OR salpingotomy if still desires fertility
Post operative methotrexate: if hCG do not normalise

Question 12

Expectant management

Answer 12

• All of the following must be present:
  = Clinically stable and pain-free
  = Unruptured ectopic size < 35 mm with no visible heartbeat on TVUS
  = Serum hCG <1500 IU/L initially, and falling

Close monitoring over 48 hours, with intervention required if further symptoms develop or hCG levels rise
Px must return for follow-up to be eligible for expectant management

Question 13

Medical management

Answer 13

FIRST LINE - Methotrexate - all of the following features must be present:
= No significant pain
= Unruptured ectopic size < 35 mm with no visible heartbeat on TVUS
= Serum hCG 1500-5000 IU/L
= No intrauterine pregnancy (confirmed on ultrasound)

Surgery can also be considered

Question 14

Surgical management

Answer 14

FIRST LINE =
Laparoscopic salpingectomy or salpingotomy
- FL if one of the following is present:
- Significant pain
- Ectopic size ≥ 35 mm
- Foetal heartbeat visible on TVUS
- Serum hCG ≥ 5000 IU/L

Question 15

Anti-D prophylaxis

Answer 15

• Anti-D rhesus prophylaxis (250 IU) for all rhesus-negative women who will undergo surgical management
• Do not offer anti-D rhesus prophylaxis for patients being treated with medical or expectant management

Question 16

Complications

Answer 16

• Rupture : can result in significant haemodynamic instability
• Recurrent ectopic
• Surgical complications
• Methotrexate side-effects:
  = nephrotoxicity,
  = hepatotoxicity,
  = pulmonary toxicity,
  = myelosuppression