Early pregnancy - ectopic, PUO, molar

Question 1

what is an ectopic pregnancy?

Answer 1

when a pregnancy is implanted outside of the uterus - most commonly in the fallopian tube

(can be entrance to fallopian tube, ovary, cervix, abdomen)

Question 2

what are some risk factors for ectopic pregnancy?

Answer 2

previous ectopic pregnancy

previous PID

previous surgery to fallopian tubes

intrauterine devices

older age

smoking

Question 3

how does an ectopic pregnancy present?

Answer 3

typically around 6-8 weeks gestation

missed period

constant lower abdominal pain in right or left iliac fossa

vaginal bleeding

lower abdominal or pelvic tenderness

cervical motion tenderness

Question 4

what are 2 important things to ask about when suspecting an ectopic pregnancy?

Answer 4

dizziness or syncope

shoulder tip pain

Question 5

what examinations would you do for ectopic?

Answer 5

abdominal exam

speculum

bimanual

Question 6

what is the investigation of choice and what are the findings for ectopic?

Answer 6

transvaginal ultrasound scan

gestational sac containing a yolk sac or fetal pole may be seen in the fallopian tube

may see a non-specific mass in the tube - refered to as blob sign, bagel sign or tubal ring sign

mass representing a tubal ectopic pregnancy moves separately to the ovary

may see an empty uterus or fluid in the uterus

Question 7

what is pregnancy of unknown location?

Answer 7

when woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan

Question 8

how will the hCG level change in a normal uterine pregnancy?

Answer 8

serum hCG will roughly double every 48 hours

Question 9

what is a rise of 63% after 48 hours likely to indicate and what is done following this?

Answer 9

intrauterine pregnancy

repeat ultrasound scan required after 1-2 weeks to confirm intrauterine pregnancy

should be visible on uss once hCG is above 1500 IU/L

Question 10

when should a pregnancy be visible on uss?

Answer 10

once hCG is above 1500 IU/L

Question 11

What does a rise of less than 63% in 48 hours indicate?

Answer 11

ectopic pregnancy

monitor pt

Question 12

what does a fall of more than 50% indicate?

Answer 12

miscarriage

urinary pregnancy test should be performed after 2 weeks to conform miscarriage is complete

Question 13

what are the 3 management options for ectopic pregnancy?

Answer 13

expectant management - natural termination

medical management - methotrexate

surgical management - salpingectomy or salpingotomy

Question 14

what is the criteria for expectant management?

Answer 14

• 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 15

what is the criteria for mangement with methotrexate?

Answer 15

same as expectant except

• HCG level must be <5000 IU/L
• conformed absence of intrauterine pregnancy on uss

Question 16

how is an ectopic managed with methotrexate

Answer 16

IM injection into buttock

halts progress of pregnancy as it is teratogenic and results in spontaneous labour

advised not to get pregnant for 3 months following treatment as harmful effects can last this long

Question 17

what are some common side effects of methotrexate?

Answer 17

vaginal bleeding

nausea and vomiting

abdominal pain

stomatitis

Question 18

those who don’t meet criteria for expectant or medical management will require surgical management - most people with ectopic require surgical

what is the criteria

Answer 18

pain

adnexal mass >35mm

visible heart beat

HCG levels >5000 IU/L

Question 19

what are the 2 options for surgical management of ectopic pregnancy?

Answer 19

laparoscopic salpingectomy

laparoscopic salpingotomy

(increased risk of failure to remove ectopic pregnancy with salpingotomy compared to salpingectomy)

Question 20

what is a laparoscopic salpingectomy?

Answer 20

1st line

GA and key-hole surgery to remove affected fallopian tube and ectopic inside tube

Question 21

what is a laparoscopic salpingotomy?

Answer 21

used in women with increased risk of infertility due to damage to the other tube

aim to avoid removing the affected fallopian tube

cut made in tube to remove ectopic and tube is closed

Question 22

whats needs to be done regarding anti-rehsus d if a woman has surgical management?

Answer 22

anti-rhesus D prophylaxis is given to rhesus negative women having surgical mangement of ectopic pregnancy

Question 23

what is a molar pregnancy? and what are the 2 types?

Answer 23

hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus

2 types: complete mole and partial mole

Question 24

what is a complete mole?

Answer 24

occurs when 2 sperm cells fertilise an ovum that contains no genetic material

sperm then combine genetic material and cells start to divide and grow into a tumour - complete mole

NO fetal material

Question 25

what is a partial mole?

Answer 25

occurs when 2 sperm cells fertilise a normal ovum (containing genetic material) at the same time

new cell now has 3 sets of chromosomes

cell divides and multiplies into a tumour called partial mole

SOME fetal material may form

Question 26

what are some signs that may indicate molar pregnancy?

Answer 26

more severe morning sickness

vaginal bleeding

increased enlargement of the uterus

abnormally high hCG

thyrotoxicosis

Question 27

what is seen on uss of a molar pregnancy?

Answer 27

snowstorm appearance

Question 28

how is a molar pregnancy managed?

Answer 28

evacuation of the uterus TO remove the mole

products of conception need to be sent for histological examination to confirm molar pregnancy

pt referred to gestational trophoblastoc disease centre for follow up

hCG levels monitored until they return to normal

can metastasise and may need systemic chemotherapy