7.1 Ectopic pregnancy

Question 1

Where can an ectopic pregnancy implant and where is most common?

Answer 1

Fallopian tube
also:
entrance to Fallopian tube (cornual region)
ovary
cervix
abdomen

Question 2

Risk factors for ectopic pregnancy?

Answer 2

• Previous ectopic pregnancy
• Previous pelvic inflammatory disease
• Previous surgery to the fallopian tubes
• Intrauterine devices (coils)
• Older age
• Smoking

Question 3

Classic features / presentation of ectopic pregnancy?

Answer 3

Typically presents around 6 – 8 weeks gestation

Classic:

• Missed period
• Constant lower abdominal pain in the right or left iliac fossa
• Pelvic tenderness
• Vaginal bleeding
• Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Also ask about:

• Dizziness or syncope (blood loss)
• Shoulder tip pain (peritonitis)

Question 4

US findings in ectopic?

Answer 4

Non-specific mass in tube: “blob sign”, “bagel sign” or “tubal ring sign”
- mass moves separately to the ovary (look similar to a corpus luteum but CL moves with the ovary)

Other features:

• an empty uterus
• fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)

Question 5

What is it called when woman has a positive pregnancy test but no evidence on US?

Answer 5

Pregnancy of unknown location (PUL)

Question 6

What do you do in PUL?

Answer 6

Do hCG and repeat at 48hrs:

• intrauterine pregnancy hCG should double every 48hrs
• rise of 63% still suggest intrauterine pregnancy, repeat US in 1-2wk (hCG >1500 pregnancy should be visible on US)
• rise of less than 63% suggests ectopic, close monitor/ review / manage
• fall of >50% suggests miscarriage, check for negative urine in 2 wks

Question 7

How can you manage an ectopic pregnancy?

Answer 7

• Expectant management (awaiting natural termination)
• Medical management (methotrexate)
• Surgical management (salpingectomy or salpingotomy) (most common)

Question 8

What are the criteria for expectant management of ectopic?

Answer 8

• Follow up needs to be possible to ensure successful termination
• The ectopic needs to be unruptured
• Adnexal mass < 35mm
• No visible heartbeat
• No significant pain
• HCG level < 1500 IU / l

Question 9

What are the criteria for medical/ methotrexate management of ectopic?

Answer 9

• same criteria as expectant
• hCG <5000
• Confirmed absence of intrauterine pregnancy on ultrasound

Question 10

Advice and side effects in medical / methotrexate management of ectopic?

Answer 10

Teratogenic so dont get pregnant for 3 months

IM injection in buttock

Side effects:

• Vaginal bleeding
• Nausea and vomiting
• Abdominal pain
• Stomatitis (inflammation of the mouth)

Question 11

People who don’t meet criteria for expectant or medical management of ectopics need surgical management, this would be anyone with what?

Answer 11

Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l

Question 12

What are the two options for surgical management of ectopic?

Answer 12

Laparoscopic salpingectomy
Laparoscopic salpingostomy

plus Anti-RhD to any Rh-ve women

Question 13

What happens in laparoscopic salpingectomy?

Answer 13

• 1st line
• GA
• key hole
• removal of affected Fallopian tube

Question 14

What happens in laparoscopic salpingotomy?

Answer 14

• when there is increased risk of infertility as other tube is damaged
• avoid removing the tube
• two cuts, remove pregnancy, join ends

(increased risk of not removing it)