Ectopic PG

Question 1

Ectopic PG

Answer 1

Implantation of the PG outside the normal uterine cavity

Question 2

Sites of ectopic PG

Answer 2

Fallopian tube - 95%
Ovaries- 3%
Peritoneal cavity- 1%

Question 3

MC site of ectopic PG is

Answer 3

Ampullary portion of the fallopian tube

Question 4

Other sites of ectopic PG

Answer 4

• Infundibulum/Fimbriae
• Cornual/ interstitial
• Broad ligament
• Isthmus
• Abdomen
• Cervix

Question 5

Risk factors of ectopic PG

Answer 5

• PID
• Endometriosis
• Previous ectopic PG
• B/L tubal ligation
• Copper IUD
• Smoking
• Assisted reproductive techniques
• subfertility

Question 6

T/F Questions

1. Ectopic PG is a direct cause of maternal death
2. Smoking is not associated with ectopic PG
3. IUDs are a known risk factor for ectopic PG
4. U/L tubal ligation is a risk factor for ectopic PG
5. heterotropic PG is rare and hard to Dx
6. 5% of IVF can lead to ectopic PG
7. Ectopic PG is an obstetric emergency

Answer 6

1. T
2. F
3. T
4. F- B/L is a risk factor
5. T ( coz of a IUP, hard to Dx)
6. F (only 1%)
7. T

Question 7

When is ectopic PG Diagnosed

Answer 7

between 5- 12 weeks of POA ( NEARLY ALL)

Question 8

Classic triad of presentation of ectopic PG

Answer 8

• Amenorrhea
• Abdominal pain
• Irregular bleeding

Question 9

Difference between the vaginal bleeding due to ectopic PG and miscarriage bleeding

Answer 9

• Miscarriage- fetus products. Bleeding heavy clots
• Vaginal bleeding- light bleeding

Question 10

Describe the vaginal bleeding in ectopic PG

Answer 10

Dark, red, scanty

Question 11

Describe the abdominal pain in ectopic PG

Answer 11

Sharp pain in the iliac fossa

Question 12

Sx of ectopic PG

Answer 12

• Vaginal bleeding
• abdominal pain
• Faintishness
• Urinary Sx

Question 13

ectopic PG

Signs of ectopic PG

Answer 13

• Adnexal tenderness
• Guarding and rigidity
• Cervical excitation
• Shoulder tip pain
• Acute abdomen
• Shock and collapse

Question 14

ectopic PG

Cervical excitation?

Answer 14

Put 2 fingers through the cervix and push to either sides. When pushing from the Right side, the left fallopian tube stretches and cause pain on the left side and vice versa

Question 15

ectopic PG

Dx of ectopic PG

Answer 15

• Trans vaginal USS (TVS)
• beta HCG
• FBC
• Group and save
• Sr. Progesterone

Question 16

ectopic PG

Heterotropic PG

Answer 16

Combined occurence of intrauterine and extra uterine

Question 17

ectopic PG

3 options of Mx of ectopic PG

Answer 17

• conservative Rx
• Pharmacological Mx
• Surgical Mx

Question 18

ectopic PG

Criteria for conservative Mx

Answer 18

• Clinically stable- pain free
• beta HCG - initial presentation <1500 IU/L
• Adenxal mass <3.5cm in TVUSS
• No visible heart beat
• No or minimal free fluid in pelvis
  ALL SHOULD BE PRESENT

Question 19

ectopic PG

Medical Mx of ectopic PG

Answer 19

Methotrexate IM

Question 20

ectopic PG

MTX?

Answer 20

folic acid antagonist. Inhibits DNA synthesis in trophoblastic cells

Question 21

ectopic PG

MTX given in ectopic PG will be

Answer 21

Multiple or single doses

Question 22

ectopic PG

MTX dose

Answer 22

50mg/m2 (body surface area)

Question 23

ectopic PG

Monitoring after MTX

Answer 23

3 times in the first week and weekly thereafter until Beta HCG becomes zero

Question 24

ectopic PG

Tests done during MTX Therapy

Answer 24

FBC and liver enzymes before treatment and on Day 7

Question 25

# ectopic PG Criteria for medical Mx

Answer 25

* Clinically stable - pain free * Unruptured tubal ectopic PG w an adnexal mass <35mm w/ no heart beat * beta HCG <1500 IU/L * No Intrauterine PG (upon USS) * No evidence of hemoperitoneum on USS * Pt consents for medical Mx * Pt is able to come for regular follow up

Question 26

# ectopic PG Surgical methods

Answer 26

* Salpingectomy * Salpingotomy

Question 27

# ectopic PG Salpingectomy

Answer 27

removal of the tube

Question 28

# ectopic PG Salpingotomy

Answer 28

incision into the tube to remove an ectopic PG

Question 29

# ectopic PG Criteria for surgical Mx

Answer 29

* Ectopic w/ significant pain * Adnexal mass >3.5cm * Sr. beta HCG >5000 IU/L * FHB + * Pt is not willing to undergo medical MX * Pt is unable to return for follow- up

Question 30

# ectopic PG When to offer a salpingectomy

Answer 30

to women undergoing surgery for an ectopic PG unless they have other risk factors for infertility- **Other tube is normal**

Question 31

# ectopic PG When to offer Salpingotomy

Answer 31

as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage

Question 32

# ectopic PG Surgical Methods done

Answer 32

* Laparoscopic - better, 1st line if stable * Laparotomy- if hemodynamically stable

Question 33

# ectopic PG How long should you avoid PG after MTX Rx

Answer 33

for 3 months

Question 34

# ectopic PG Better reproductive outcome for a woman with a subfertility Hx

Answer 34

Conservative and medical Mx

Question 35

# Ectopic PG TVS findings

Answer 35

* Empty uterus * Pseudo sac * Adnexal mass * Presence of free fluids

Question 36

# Ectopic PG how to differentiate IUP and ectopic PG from beta HCG levels

Answer 36

Viable IUP beta HCG levels doubles every 2 days

Question 37

# Ectopic PG Group and save

Answer 37

Cross match 1 unit of blood and keep in case it's needed

Question 38

# Ectopic PG Ectopic PG implanted on.... can go unruptured upto >= 12 weeks

Answer 38

Cornual/ interstitial

Question 39

# Ectopic PG Ectopic PG implanted on the isthmus can get ruputured as early as ....

Answer 39

4 weeks

Question 40

# Ectopic PG Most prominent Sx

Answer 40

Abdominal pain

Question 41

# Ectopic PG Describe the pain in a ruptured Ectopic PG

Answer 41

* Sudden onset of pain

Question 42

# Ectopic PG Describe the pain in chronic Ectopic PG

Answer 42

Aching type of pain

Question 43

# Ectopic PG Sx and signs Patient will present with if the ectopy is ruptured

Answer 43

General condition will be poor with pallor, tachycardia and low BP

Question 44

# Ectopic PG Patient's general condition if the ectopy is not ruptured

Answer 44

will be satisfactory

Question 45

# Ectopic PG Signs suggesting ruptured ectopy

Answer 45

* Adnexal tenderness * Guarding and rigidity * Shock * Collapse

Question 46

# Ectopic PG Is a PV examination essential in Dx ectopic PG

Answer 46

not essential but helpful

Question 47

# Ectopic PG PV exam should be done in the hospital due to the risk of

Answer 47

rupture

Question 48

# Ectopic PG Significant fluid in the pelvis suggests

Answer 48

Ruptured ectopic PG

Question 49

# Ectopic PG MTX second dose is given if

Answer 49

the beta hCG levels on D7 compared to D4 hasn't dropped by 15%

Question 50

# Ectopic PG After giving MTX what tests are done

Answer 50

beta hCG tested on D4 and D7 after the first dose

Question 51

# Ectopic PG Most appropriate surgical procedure

Answer 51

salpingectomy

Question 52

# Ectopic PG Ectopic PG should be suspected in women of childbearing age, who complains of abdominal pain even in the absence of POA. (T/F?)

Answer 52

TRUE

Question 53

# Ectopic PG Bets hCG should be tested on... after surgical procedure

Answer 53

1 week post- op and weekly until the levels become negative

Question 54

# Ectopic PG If the pt presents with Sx of ectopy and the TVS cannot detect it whats the next step

Answer 54

do a beta hCG testing and repeat TVS and beta hCG again after 48h

Question 55

# Ectopic PG If the rise between the two beta hCG testing done when TVS cannot detect the ectopy is **less than 63% and there is no IUP.**

Answer 55

suspect Ectopy or PG in an unknown location. confirm by laparoscopy

Question 56

# Ectopic PG If the rise between the two beta hCG testing done when TVS cannot detect the ectopy is** more than 63% and there is no IUP.**

Answer 56

confirm a developing IUP. and repeat TVUS in 3- 7 days

Question 57

# Ectopic PG If the rise between the two beta hCG testing done when TVS cannot detect the ectopy falls by more than 50% and there is no IUP.

Answer 57

Dx as a non viable PG