Early Pregnancy Complication - Ectopic pregnancy

Question 1

What is the incidence of ectopic pregnancy?

Answer 1

11/1000

Question 2

False +ve rate for Dx Lap for ectopic pregnancy?

Answer 2

5%

Question 3

False -ve rate for Dx Lap for ectopic pregnancy?

Answer 3

3-4%

Question 4

At what bHCG would you expect to see a viable intra-uterine pregnancy on TV USS?

Abdo USS

Answer 4

TVUS: 1500-1800
Abdo USS: 6000-6500

Question 5

List the types of ectopic pregnancy starting with the most common type in descending order, extra points for %

Answer 5

Ampulla 55%
Isthmus 25%
Fibriale 17%
Cornual 2%
Ovarian 0.5%
Intra-abdominal 0.1%

Question 6

Risk factors for ectopic pregnancy?

Answer 6

PID
IUCD
Sterilisation
Tubal surgery
Previous ectopic
Assisted reproduction
Mini-pill

Question 7

What is the most common finding on TVUS in ectopic pregnancy? What other findings might you see?

Answer 7

1. Inhomogenous adenxal mass - 60% - sperate from ovary ‘tubal ring’ or ‘bagel sign’
2. Empty extrauterine gestational sac 20-40%
3. Extra uterine embryonic pole +/- cardiac activity 15-20%
4. Collection of fluid inside uterine cavity ‘pseudo sac’ 20%
5. Same side as corpus luteum in 70-85% (ring of fire)

?Haemoperitoneum

Question 8

What % of women with ectopic pregnancies have NO risk factors?

Answer 8

1/3rd

Question 9

If < 6 weeks pregnanct and bleeding alone (no pain), how to manage?

Answer 9

Conservative - repeat pregnancy test in 7-10days, return if +ve
Safety net - heavy bleeding, pain return
If negative pregnancy test → miscarried

Question 10

Who is eligible for expectant management?

Answer 10

1. Clinically stable & pain free
2. Tubal ectopic <35mm and no HB
3. bHCG <1000, consider <1500
4. Are able to return for follow up

Question 11

How should expectant management of ectopic pregnancy be followed up?

Answer 11

bHCG on D 2, 4 and 7

• bHCG must drop by 15% from previous value
• Continue weekly follow up until bHCG <20

Question 12

What outcomes are the same for expectant and medical management?

Answer 12

• Rate of future ectopic
• Risk of tubal rupture
• Need for additional Tx
• Health status, depression/anxiety

Question 13

Who can have medical management of ectopic pregnancy?

Answer 13

• No significant pain
• Unruptured tubal ectopic <35mm, no HB
• bHCG <1500, consider upto 5000
• No intrauterine pregnancy
• Can return to follow up
• No CI to MTX

Question 14

How is MTX given and what follow up?

Answer 14

• Must be certain of Dx
• Single dose 50mg/m2
• bHCG day 4 & 7 → 15% drop, then weekly entail <15
• Can consider 2nd dose

Question 15

What advise should be given when giving MTX?
What SE should you warn against?

Answer 15

Must avoid ETOH & folate containing vitamins
Avoid sexual intercourse during Tx
Should use reliable contraction for 3 months after (teratogenic)
Drink plenty of fluids

Adverse - marrow suppression, pulmonary fibrosis, pneumonitis, liver cirrhosis, renal failure, gastric ulcers, flatulance, mildly raised LFT

Question 16

Success rates of Medical Mgmt miscarriage? How many need 2nd dose of MTX?

Answer 16

65-95%
3-25% need second dose

Question 17

Who should be offered surgical mgmt for ectopic pregnancy?

Answer 17

• Significant pain
• > 35mm
• Visible heart beat
• bHCG >5,000
• Unable to attend FU
• Ruptured ectopic

Question 18

When should salpingotomy be considered over salpingectomy?

Answer 18

RF for infertility, contralateral tube damage (prev ectopic, prv PID, prv abdo surgery)

Question 19

If salpingotomy is performed, how many will require further treatment?

Answer 19

1/5
Either repeat surgery or MTX

Question 20

If saplingotomy is performed what FU should be arranged?

Answer 20

Recheck bHCG in 7 days, then 1 per week until negative result

Question 21

If salpingectomy is perfumed what follow should be arranged?

Answer 21

Repeat UPT after 3 weeks, to contact if +ve

Question 22

What are the recurrence rates of ectopic pregnancy?

After 2 ectopics?

Answer 22

18.5%

1 previous 10%
2+ 25%

Question 23

If mother is Rh-ve, which mothers need anti D?

Answer 23

Surgical mgmt of ectopic or miscarriage

Do not give if medical mgmt miscarriage/ectopic
Miscarriage
PUL

Question 24

How to manage pregnancy unknown location?

Answer 24

Explain, safety net TCI - pain/unwell etc

Take 2 bHCG 48 hrs apart

Question 25

In PUL, if developing intrauterine pregnancy, what change would be seen between bHCG? How to manage?

Answer 25

Increase in 63% or over after 48hrs TVUS 7-14 days later, if not seen review by senior

Question 26

In PUL, if pregnancy unlikely to continue, what change would be seen between bHCG? How to manage?

Answer 26

Decrease in bHCG by 50% or greater - UPT in 14 days → if negative no further action → If +ve for USS - Offer support and counselling

Question 27

In PUL, if possible ectopic pregnancy, what change would be seen between bHCG? How to manage?

Answer 27

Decrease less than 50%, or increase less that 63% Clinical review

Question 28

What will be see on USS for interstitial ectopic? When do they rupture?

Answer 28

Empty uterine cavity Product in interstitial part of tube, <5mm myometrium in all imaging planes Interstitial line sign 8-16 weeks, very vascular (ovarian and uterine blood supply)

Question 29

What will be seen on USS in cervical ectopic?

Answer 29

Empty endometrial cavity Gestation sac at or below levy of interval cervical Os Absence of sliding sign

Question 30

Management of cervical ectopic

Answer 30

High surgical failure rates, given MTX unless bHCG >10,000 If heavy bleeding hysterectomy

Question 31

What is the incidence of CS scar ectopic?

Answer 31

1 in 2000 (increasing)

Question 32

USS features of CS scar ectopic?

Answer 32

Empty endometrial cavity Gestation sac located lower anterior myometrium at level of CS scar, askance sliding sing 13% misdiagnosed as intrauterine or cerival

Question 33

Mgmt of CS scar ectopic prengnancy

Answer 33

Medical - USS guidance injection into gestation sac of MTX. Consider is <8/40 and bHCG <5000, stable Surgical - evacuation of pregnancy (suction or hysteroscopy) or Lap/open excision Expectant only if non viable pregnancy or only partially implanted. High risk of maternal morbidty/hysterectomy in 2nd trimester

Question 34

Risk of recurrence with CS scar ectopic?

Answer 34

3.2-5%

Question 35

Dx of ovarian ectopic and mgmt?

Answer 35

Non specific on USS - negative sliding sign, corpus separate. Dx confirmed surgically. Lap surgical options preferred. Can give MTX if surgical high risk, but 40% failure rate

Question 36

Mgmt heterotopic pregnancy

Answer 36

Must consider intrauterine prengnancy Only MXT if not viable intauterine or woman does not wish to continue pregnancy Local injection with KCL to hyperosmolar glucose Surgical if unstable

Question 37

When to consider heterotypic pregnancy? Is bHCG useful in Dx?

Answer 37

Consider IVF Intrauterine pregnancy but ongoing pain or persistently raised bHCG after miscarriage or TOP bHCG not helpful