25. Ectopic Pregnancy

Question 1

What is the definition of an ectopic pregnancy?

Answer 1

Any pregnancy that occurs outside the uterine cavity.

Question 2

Where can ectopic pregnancies implant?

Answer 2

• Fallopian tubes (most common)
• Cornua of the uterus
• Cervix
• Ovary
• Abdominal cavity (extra-uterine)

Question 3

What is a chronic ectopic pregnancy?

Answer 3

A condition where the conceptus is resorbed, but adhesion formation leads to a painful mass.

Question 4

What is the most common cause of ectopic pregnancy in the patient population?

Answer 4

Pelvic Inflammatory Disease (PID).

Question 5

How does PID contribute to ectopic pregnancy?

Answer 5

Acute salpingitis (inflammation of the fallopian tubes) leads to adhesions within hours of infection with Chlamydia or Gonococcus, impairing tubal transport.

Question 6

What is the risk of a repeat ectopic pregnancy after a previous one?

Answer 6

25% risk of another ectopic pregnancy.

Question 7

How does progestogen-only contraception contribute to ectopic pregnancy risk?

Answer 7

It may slow tubal motility, increasing the chance of ectopic implantation. However, overall, it effectively prevents pregnancy and reduces overall ectopic risk.

Question 8

What other factors increase the risk of ectopic pregnancy?

Answer 8

• Previous pelvic surgery leading to adhesions
• Anatomical distortion of the fallopian tubes due to endometriosis
• Assisted reproductive techniques (due to drugs used or underlying tubal damage)
• Current use of an Intrauterine Contraceptive Device (IUCD) (mild association)

Question 9

How does the incidence of ectopic pregnancy relate to PID?

Answer 9

It is directly proportional to PID incidence and is increasing due to the rising prevalence of pelvic infections.

Question 10

What is the approximate incidence of ectopic pregnancy?

Answer 10

1% of conceptions result in ectopic pregnancy.

Question 11

What are the classic symptoms of ectopic pregnancy?

Answer 11

• Amenorrhoea
• Unilateral pelvic pain
• Collapse (in severe cases)

Question 12

What are the clinical signs of a ruptured ectopic pregnancy?

Answer 12

• Shock
• Pelvic peritonitis
• Cervical excitation tenderness
• Palpable unilateral pelvic mass (may not always be elicited due to tenderness)

Question 13

Why is a high index of suspicion required for ectopic pregnancy?

Answer 13

Presentation can be subtle, and symptoms vary widely.

Question 14

In which women should ectopic pregnancy always be suspected?

Answer 14

Any sexually active woman (even if using contraception) presenting with:
- Abnormal vaginal bleeding
- Pelvic pain
- Possible or unrecognized pregnancy

Question 15

What gynaecological conditions should be considered in the differential diagnosis of ectopic pregnancy?

Answer 15

• Pelvic Inflammatory Disease (Always do a pregnancy test!)
• Rupture, haemorrhage, or torsion of an ovarian cyst
• Threatened or inevitable miscarriage
• Red degeneration of a fibroid in pregnancy (rare in the first trimester)
• Gestational trophoblastic disease with corpus luteal cyst complications

Question 16

What should always be assumed in a pregnant woman with pain and bleeding until proven otherwise?

Answer 16

An ectopic pregnancy.

Question 17

Why should pelvic examination be performed gently in suspected ectopic pregnancy?

Answer 17

To avoid rupturing an intact ectopic gestational sac.

Question 18

How can a pregnancy test help in diagnosing an ectopic pregnancy?

Answer 18

A sensitive urine test (25-50 IU/ml) can establish pregnancy, but a serum β-hCG is more accurate.

Question 19

What should be done if a urine pregnancy test is equivocal?

Answer 19

Check serum β-hCG levels and repeat in 48 hours if necessary.

Question 20

What is the expected rise in β-hCG in a viable intrauterine pregnancy?

Answer 20

Previously: Doubling every 48 hours.

Now: A rise of ≥66% is considered normal, but a rise <53% suggests a non-viable pregnancy (ectopic or miscarriage).

Question 21

Can β-hCG levels alone rule out ectopic pregnancy?

Answer 21

No. Ruptured and unruptured ectopic pregnancies have been identified with β-hCG levels from <100 IU/L to >50,000 IU/L.

Question 22

What is the main purpose of an ultrasound in suspected ectopic pregnancy?

Answer 22

To determine if there is an intrauterine pregnancy (IUP).

Question 23

What ultrasound findings suggest an ectopic pregnancy?

Answer 23

• No intrauterine gestational sac with a positive pregnancy test.
• Adnexal mass (especially with fetal heart activity).
• Free fluid in the pelvis.

Question 24

At what β-hCG level should an intrauterine pregnancy be visible on ultrasound?

Answer 24

• Vaginal scan: ≥1500 IU/L.
• Abdominal scan: ≥6500 IU/L.

Question 25

What does failure to detect an intrauterine pregnancy at these levels suggest?

Answer 25

Ectopic pregnancy.

Question 26

When is laparoscopy/laparotomy needed for ectopic pregnancy?

Answer 26

If the diagnosis remains unclear after other investigations.

Question 27

What is the benefit of laparoscopy in suspected ectopic pregnancy?

Answer 27

It provides a definitive diagnosis and allows for immediate surgical removal.

Question 28

What test can be used if ultrasound and laparoscopy are unavailable?

Answer 28

Colpo-puncture (aspiration from the pouch of Douglas).

Question 29

What does the presence of blood or serum in the colpo-puncture suggest?

Answer 29

Possible ectopic pregnancy, requiring further investigation.

Question 30

What is the role of D&C in ectopic pregnancy diagnosis?

Answer 30

Chorionic villi in endometrial tissue confirm intrauterine pregnancy. Absence of chorionic villi suggests an ectopic pregnancy.

Question 31

When can expectant management be considered?

Answer 31

- Patient is stable. - Low β-hCG levels. - Spontaneous regression expected. - Requires close follow-up

Question 32

What is a major disadvantage of expectant management?

Answer 32

Longer hospital stay with risk of rupture.

Question 33

What is the most commonly used medical treatment for ectopic pregnancy?

Answer 33

Methotrexate (a folic acid antagonist).

Question 34

How does Methotrexate work?

Answer 34

Disrupts DNA/RNA of rapidly dividing trophoblastic cells.

Question 35

What are other agents used for medical management?

Answer 35

Hyperosmolar glucose, prostaglandins, mifepristone (anti-progesterone).

Question 36

❓ What are the eligibility criteria for medical therapy?

Answer 36

✅ - Easy follow-up. ✅ - Minimal symptoms. ✅ - β-hCG < 3000 IU/L (RCOG Guideline). ✅ - No contraindications to cytotoxic agents (e.g., liver disease, myelosuppression).

Question 37

Why should contraception be used for at least three months after Methotrexate?

Answer 37

To prevent teratogenic effects in future pregnancies.

Question 38

What is the immediate surgical approach for a ruptured ectopic pregnancy?

Answer 38

Emergency laparotomy with resuscitation.

Question 39

What procedure is commonly performed in ruptured ectopic pregnancy?

Answer 39

Partial salpingectomy (removal of part of the fallopian tube).

Question 40

When is laparotomy necessary?

Answer 40

✅ - Shock due to rupture. ✅ - Chronic ectopic pregnancy with dense adhesions or complex mass.

Question 41

What is the modern surgical approach for stable/unruptured ectopic pregnancy?

Answer 41

Laparoscopic excision or partial salpingectomy.

Question 42

What are the advantages of laparoscopic surgery over laparotomy?

Answer 42

✅ - Better cosmetic results. ✅ - Shorter hospital stay. ✅ - Faster return to normal activities. ✅ - Lower postoperative pain and morbidity.

Question 43

What is the key strategy to prevent ectopic pregnancy?

Answer 43

Reducing the incidence of PID through condom use in non-monogamous relationships.

Question 44

Why is early ultrasound important in women with a history of ectopic pregnancy?

Answer 44

To confirm intrauterine pregnancy early and reduce the risk of undiagnosed ectopic pregnancy.

Question 45

What should healthcare workers remember about ectopic pregnancy?

Answer 45

It is a subtle but dangerous condition, requiring high vigilance.

Question 46

What should be suspected in a young patient with lower abdominal pain and a positive pregnancy test?

Answer 46

Ectopic pregnancy!

Question 47

❓ What historical factors increase ectopic pregnancy risk?

Answer 47

✅ - Previous ectopic pregnancy ✅ - Previous tubal ligation (T/L) ✅ - IUCD use ✅ - History of PID

Question 48

What clinical signs should be assessed?

Answer 48

✅ - Pallor ✅ - Pulse & BP ✅ - Hemoglobin ✅ - Pelvic tenderness

Question 49

❓ What is the first step in suspected ectopic pregnancy?

Answer 49

Establish IV access and assess patient stability.

Question 50

What is the immediate management for a shocked patient?

Answer 50

Resuscitate & prepare for emergency surgery.

Question 51

What is the next step in a stable patient?

Answer 51

Perform a transvaginal ultrasound (TVS) to look for intrauterine pregnancy (IUP).

Question 52

What does an empty uterus or no ultrasound availability indicate?

Answer 52

Perform quantitative βhCG testing.

Question 53

What are the differential diagnoses if no intrauterine pregnancy is found?

Answer 53

✅ - Ectopic pregnancy ✅ - Missed miscarriage ✅ - Early pregnancy (if no TVS done)

Question 54

What is the significance of βhCG ≤ 1500 IU?

Answer 54

Repeat βhCG in 48 hours.

Question 55

❓ What does a βhCG rise of >66% in 48 hours indicate?

Answer 55

✅ Likely a viable intrauterine pregnancy (IUP).

Question 56

What does a βhCG rise of <53% in 48 hours indicate?

Answer 56

Possible ectopic or non-viable pregnancy.

Question 57

When should a repeat scan be performed?

Answer 57

If βhCG > 1500 IU and no intrauterine pregnancy seen.

Question 58

What clinical signs require urgent intervention?

Answer 58

✅ - Increasing pain/tenderness ✅ - Drop in hemoglobin ✅ - Hypotension & tachycardia

Question 59

❓ If in doubt, what is the definitive diagnostic procedure?

Answer 59

✅ Laparoscopy or laparotomy.