Ectopic pregnancy

Question 1

A 30 year old lady has presented to ED with PV bleeding. Her last menstrual period was 5 weeks ago. She has mild lower abdominal cramps. how will you assess and manage her?

Answer 1

Impression
Provisionally, am concerned about a ruptured ectopic pregnancy and would want to rule this out as this is a medical emergency demanding urgent treatment and management

Ddx to consider

• Obstetric: Implantation bleed, threatened miscarriage/incomplete/complete miscarriage, TOP complication, GTD
• Gynaecological: Ectopic, heavy menstrual bleeding, irregular periods, malignancy (cervical, endometrial), PID, foreign body, trauma, assault, ovarian cyst rupture, torsion.

Goals

• rule out life-threatening and ectopic pregnancy, consider if pregnant and wether this is spontaneous abortion
• targeted Hx/Ex/Ix, then appropriate management with O&G referral as appropriate

Question 2

Ectopic pregnancy - Assessment

Answer 2

Assessment
- call for senior help
- early O&G referral
A - patent, maintaining
B - RR/SP02, supplemental as required
C - BP/ECG/HR monitoring (?HD unstable). 2xIVC, initial bloods: VBG, FBC, UEC, CRP/ESR, G+H, BSL, ß-HCG. If shocked administer fluid bolus, request 3u 0- for blood transfusion (like for like). Consider need for inotropic support. Urgent theatres for definitive mx
D - GCS
E - temp, etc, eFAST scan for free abdominal fluid

Question 3

Ectopic pregnancy - History

Answer 3

History

• PC: pain (SOCRATES), bleeding (volume, timing, relationship to pain), associated features (mucous, purulent discharge, etc), sudden increase in abdo pain (rupture), shoulder tip pain?
• menstrual: regular periods?, volume, timing, LMP. ?pregnant vs known pregnancy?
• Sexual history: practices, partners, protection? STI testing if at risk
• Last meal, PMHx, medications, allergies

Question 4

Ectopic pregnancy - Examination

Answer 4

Examination
- vitals
- general appearance
- abdo: peritonitis, localised tenderness, distensions, enlarged uterus (GTD)
Pelvic
- speculum: site of bleeding, vaginal/cervical abnormalities (ectropion, polyps), cervical dilation +/- POC
- bi-manual: adnexal mass, cervical motion tenderness

Question 5

Ectopic pregnancy - Investigations

Answer 5

Investigations

• Bedside: urine ß-HCG, eFAST, AXR, PV/TA U/S assessing for evidence of pregnancy, snowstorm uterus
• Bloods: serial ß-HCG (look for trend), Rh, rest as per A to

Question 6

Ectopic pregnancy - Management

Answer 6

Management
- early O&G referral

Definitive
depends on diagnosis
- Ectopic: unstable then theatres for laparoscopic salpingostomy/salpingectomy +/- methotrexate and IV empirical ABx, stable then MTX if not contraindicated
- Miscarriage
o threatened: expectant
o partical: medical mx (misoprostol), surgical (D&C)
- GTD: MTX + D&C + serial ß-HCG

Supportive

• analgesia
• fluid resus as required
• ABx if indicated based on likely diagnosis
• counselling referral
• STI/CST screening as appropriate
• pre-conception screening