Ectopic Pregnancy

Question 1

What is ectopic pregnancy ?

Answer 1

It’s a condition where the developing blastocyst becomes implanted at a site other than the endometrium of e uterine cavity .

Question 2

There’s a seasonal variation occueswit ectopic pregnancy so it is more common in ?

Answer 2

June and December

Question 3

The overall incidence of ectopic pregnancy among women with first trimester bleeding with pain is ?

Answer 3

6-16%

Question 4

Most common site for ectopic pregnancy is ?

Answer 4

Fallopian tube 98%

Question 5

Rare sites for ectopic pregnancy ?

Answer 5

-Heterotopic pregnancy
-Hysterectomy scar pregnancy
-rudimentary uterine horn pregnancy

Question 6

Sites for ectopic pregnancy other than fallopian tubes?

Answer 6

Ampullary
Ovarian
Abdominal
Cervical
Isthmic
Interstitial

Question 7

High Risk factors for ectopic pregnancy ?

Answer 7

-previous ectopic pregnancy 15%
Tubal surgery and pathology (infection /tumor)
-in utero DES exposure (9 folds) increase in risk

Question 8

Moderate risk factors ?

Answer 8

-Previous genitalia infection (especially with chlamydial infection .
-IUD (if pregnancy occurs while using IUD then the women is in a high risk for having ectopic pregnancy

Question 9

Mild ectopic pregnancy risk factor ?

Answer 9

-Smoking
-Age less than 18 at first sexual encounter
- multiple sexual partner

Question 10

The classic symptoms of ectopic pregnancy ?

Answer 10

Abdominal pain
Amenorrhea
Vaginal bleeding

Question 11

Associated symptoms with ectopic pregnancy other than the classic tirade ??

Answer 11

-Shoulder pain (due to diaphragm irritation )
-Difficult defecation (due to pooling of blood in pouch of Douglas )
-lightheadness due to tubal rapture

Question 12

Ectopic pregnancy physical examination findings ?

Answer 12

-Low grade fever
-Orthostatic changes on vital signs
-abdominal tendrness
-mild uterine enlargement
-adnexal mass

Question 13

How do diagnose ectopic pregnancy ?

Answer 13

-us (transvaginal )

Question 14

Transvaginal findings for ectopic pregnancy (pseudo sac) ?

Answer 14

• pseudo sac : small fluid collection that is located within centrally within the endometrial cavity and surrounded with hick decidual reaction .
• absence of double decidual sac sign
  -tends to be located in the middle of the uterine cavity
  Can change in shape during the sac
  Decrease blood flow on Doppler

Question 15

The presence of a yolk sac with in the endometrium is diagnostic for?

Answer 15

Intrauterine pregnancy

Question 16

Adnexal findings are suggestive for ?

Answer 16

Tubal pregnancy
Non cystic adnexal mass

Question 17

Echogenic peritoneal free fluid is almost always a representation for ?

Answer 17

Hemoperitoneum

Question 18

Human chorionic gonadotropin as an investigational tool for ectopic pregnancy ?

Answer 18

-The mean doubling time for the hermone range between 1.4 to 2.1 days
HCG concentration rise by 66% every 48 hour during 40 days of pregnancy

Question 19

What is the discriminatory zone

Answer 19

A level of hcg above it gestational sac should be visualized by us if there is an intrauterine pregnancy

Question 20

The level of hcg in he discriminatory zone ?

Answer 20

1500 to 2000 (transvaginal)
6500
(Trans abdominal )

Question 21

Progesterone as a diagnostic tool for ectopic pregnancy ?

Answer 21

The level of it are higher in viable intrauterine pregnancy

Question 22

When we use curettage for ectopic pregnancy diagnosis?

Answer 22

When we are curtain of non viable intrauterine pregnancy

Question 23

What are the indications for surgical treatment in the cases of ectopic pregnancy ?

Answer 23

-Hemodynamic instability
- methotrexate contraindications
- ongoing rapture ectopic mass
- lack of timely access to medical institutions
-desire for permanent contraceptives
- failed medical therapy
-coexisting intrauterine pregnancy
-

Question 24

Which surgical approach is preferred? Open or laparoscopy

Answer 24

The laparoscopic surgical approach is preferable.

Question 25

When to preformed saplingectomy over salpingotomy ?

Answer 25

When the other tube is healthy

Question 26

What are the Risk factors for preforming salpingotomy over saplingectomy ?

Answer 26

• risk for further treatments such as the need of doing saplingectomy or he need to use methotrexate

Question 27

The follow up that should be done for a women after salpingotomy ?

Answer 27

B- Hcg levels

Question 28

Medical treatment that’s used for ectopic pregnancy?

Answer 28

Methotrexate

Question 29

The mechanism of action for methotrexate in treating the ectopic pregnancy ?

Answer 29

Folic acid antagonist on a dose of 50 mg /m2

Question 30

How are the patients that optimal for medical treatment in ectopic pregnancy ?

Answer 30

-no fetal cardiac activity
- hemodynamically sable
- when the hcg levels concentration are less than 5000 units

Question 31

Contraindications for using methotrexate

Answer 31

• hemodynamically unstable
• hypersensitivity to methotrexate
• immunodeficiency patients
  -breastfeeding
  -coexisting intrauterine pregnancy
  -don’t have timely access to medical institution .
• signs of impending or ongoing mass rapture

Question 32

What are the signs of impending mass rapture ?

Answer 32

Abdominal sever pain
More than 300 ml free pertonial fluid outside pelvic cavity

Question 33

Relative contraindication for using methotrexate ?

Answer 33

High hcg level
Large ectopic size more than 3,5
High level of flic acid
Sonographic event of yolk sac
Isthmic location of ectopic mass
Fluid in pelvis

Question 34

What is expectant management for ectopic pregnancy ?

Answer 34

When you expect the ectopic pregnancy to resolve by itself without any intervention (you just observe them in the hospital )

Question 35

Candidates for expectant management ?

Answer 35

Transvaginal ultrasound doesn’t show a gestational sac
Low hcg (less than 200)