Ectopic Pregnancy

Question 1

A 25 year-old woman presents with severe lower abdominal pain and tenderness. Her last period was 6 weeks ago. How would you assess and manage her?

Answer 1

Impression
With severe lower abdominal pain, I am initially concerned about an acute abdomen. There are several potential causes of this presentation, however of note, given the woman is of reproductive age and has not had a period for 6 weeks, I am concerned about a potential ectopic pregnancy and ?rupture.

other key differentials of an acute abdomen I would need to consider include;

• gynae: ovarian torsion, PID, ovarian cyst rupture
• GIT: appendicitis, bowel perforation, caecal volvulus
• Renal: UTiI, pyelonephritis, renal colic

Question 2

Ectopic pregnancy - Assessment

Answer 2

Assessment
Given the severity of this presentation, I would call for senior help and request an urgent O&G surgical consult. In the interim I would move patient to a resus bay and start my assessment by taking an ABCDE approach;

A - Patent, maintaining
B - RR, SP02, supplemental 02 as required
C - BP, ECG, 2xIVC, address any haemodynamic instability by starting fluids +/- blood resuscitation, take bloods - VBG, ßHCG urine/serum to confirm pregnancy, FBC, blood group + hold, rhesus, UEC, LFT (prior to methotrexate)
D
E - temperature, secondary surveys, BSL, consider conducting an eFAST scan to check for abdominal fluid

Question 3

Ectopic pregnancy - History

Answer 3

History
ask patient if they could possibly be pregnant, unprotected sex in past 2 months, contraception, etc
- sx: SOCRATES, PV bleeding, amenorrhoea, lower abdo pain, any systemic features (fevers), acute abdomen
- obstetric hx: gravidity, parity, LMP, rhesus status
- gynae hx: contraception, menstrual cycle, sexual hx, past STIs
- PMHx/SHx: abdominal surgeries
- Medications, allergies
- last meal

Question 4

Ectopic pregnancy - Examination

Answer 4

Examination

• general appearance + vitals
• abdominal examination: signs of peritonism, focal tenderness, enlarged uterus
• pelvic examiantion: speculum + bimanual: Os open/closed, volume/site of bleeding, adnexal mass on palpation, motion tenderness

Question 5

Ectopic pregnancy - Investigations

Answer 5

Investigations
- Key/diagnostic: ß-HCG (urinary + serum), TV-US - visualise pregnancy outside of uterus - will only be able to visualise if ß-HCG is >1500-2000. and serial ß-HCG every 48-72 hours in order to observe management effectiveness and inform need for definitive treatments

• Bedside: as per A to E assessment
• Bloods: as above

Question 6

Ectopic pregnancy - Management

Answer 6

Management
Depends on whether patient is stable or not, if unstable then begin resus as above and call for urgent O&G consult/review with a view to theatres.

Conservative
- expectant management if ß-HCG is already declining

Medical (preferred)

• single dose of methotrexate IM to terminate the pregnancy
• administer anti-D immunoglobulin if patient is rhesus negative

Surgical
- laparoscopy with salpingostomy (preserves fallopian tubes)/salpingectomy. used in setting of failed medical management, or if haemodynamically unstable and complications (e.g. rupture)

Follow-up

• CST
• STI screen