Ectopic Flashcards
Name the four sites of the fallopian tube and where ectopics commonly happen, and where they can rupture commonly
Fimbriae
Infundibulum
Ampulla - 73 percent of ectopics
Isthmus - common site of rupture
What do you call it when someone has an intrauterine and extrauterine pregnancy at the same time?
Heterotropic pregnancy
What three things are important for the migration of the egg to the uterus?
Cilia motion
Tubal fluid
Tubal peristalsis
RF for ectopic
Damage to fallopian tubes from PID, STI, tubal surgery, chronic salpingitis, salpingitis isthmica nodosa
Previous ectopics
IUS/IUD
SMOKING
also endometriosis
progesterone contraceptive - slows down cilia
Signs and symptoms
Lower abdominal pain
Bleeding
Shoulder tip pain if rupture has caused haemoperitoneum and peritonitis
Collapse, dizziness, amenorrhoea, D and V
Investigations
A to E approach
Basic obs
Abdo and pelvic exam
Bimanual speculum
Urine/serum pregnancy test
Bloods - beta HCG, FBC, U and E (kidney stones), group and save, CRP (appendicitis)
TVUSSA
What would be seen on TVUSS/bimanual?
Adnexal mass on TVUSS
Bimanual - adnexal tenderness
Differentials
TINCANBEDS
T - ovarian torsion
I - appendicitis, PID
N - molar preganncy
C
A
N
B
E - kidney stones
D
S - ovarian torsion, kidney stones
PID
Miscarriage
Molar pregnancy
Ovarian torsion
How would an ectopic in the tubes present differently from if they were in the ovaries?
If in tubes - smaller space therefore presents within 6-8 weeks of conception
If in ovary, more space to grow therefore would present a lot later
How should beta HCG increase in a normal pregnancy?
Double if normal in 48 hours
Management if haemodynamically unstable
A to E approach
Oxygen
Two wide bore cannula
Fluid with 0.9 percent sodium chloride
Surgery - emergency laparotomy
What does bHCG do?
Takes on the role of LH, so it stimulates the corpus luteum to produce progesterone
Conservative management of an ectopic + what percentage of people have spontaneous resolutions of their ectopic?
Wait and watch
Repeat bHCG levels in TWO days
If no change and hasn’t declined, go for medical option
‘Your body naturally resolves the pregnancy’
3/4 people
Medical management + how does the drug work
IM Methotrexate - make sure U and E and LFT measured
Methotrexate = Folic acid antagonist so it inhibits DNA synthesis
bHCG levels at day 4 and day 7
Day 4 - bhcg levels rise
Day 7 - they start to fall
Then weekly until negative result is obtained
If it doesn’t decrease, surgery
Surgical management options + what they are + what is preferred
Laparoscopy = key hole
Laparotomy = reserved for if there is rupture
Laparoscopy types = salpingectomy and salpingotomy
Salpingectomy = resection of entire fallopian tube (preferred if other fallopian tube is okay)
SalpingOtomy = resection of ONLY the ectopic
What percentage of people get pregnant after a salpingectomy?
2/3 of people get preg after 18m
How would you explain why we prefer salpingectomies to salpingotomies
If there is any damage to a fallopian tube, it increases the risk of another ectopic.
So actually there is no difference in the chance of getting another ectopic between salpingotomy and salpingectomy.
Acronym for deciding the management option
Some pregancies have horrible outcomes
Size <35
Pain severity
bHCG <1000 for cons, <1500 for medical and >1500 for surgical
foetal Heart beat (if present, surgical)
Others - hemoperitoneum, Haemodynamic stability etc
When is methotrexate contraindicated
Immunosuppression
Breastfeeding
IU preg
Liver, renal or haem disorder
SE of methotrexate
N and V
Stomatitis
When would you give anti-D prophylaxis?
Give 250 IU ASAP to all women who are RhD negative after surgery
What percentage of people having salpingOtomy need methotrexate?
1/5
F/U after salpingectomy
Urine preg at 3 week
F/U after salpingotomy
serum b HCG at 1 week
then weekly until negative
