ectopic pregnancy and PID

Question 1

Tubal anatomy

Answer 1

Fimbrial end, infundibular, ampulla, isthmic, cornual portions

Question 2

Risk factors for ectopic

Answer 2

Question 3

Why does IVF increase risk of ectopic

Answer 3

Unknown - theories include:
1. Migration of transferred emrbyo into tube
2. Accidental endotubal transfer
3. Disturbed endocrinological milieu - risk of ectopic is significantly greater during a fresh compared to frozen transfer.
4. Not thought to be genetic - aneuploidy rates similar.

Question 4

Indications for salpingostomy and surgical technique

Answer 4

1. If contralateral tubal damage then salpingosotomy may increase subsequent ongoing pregnancy rate.
2. If not contralateral tube then sapingectomy or salpingotomy could be perfomred - IUP rates are similar but higher ectopic pregnancy recurrence after salpingostomy. (60% will conceive after salpingostomy, 15% ectopic pregnancy rate).
3. Small risk of not removing all the trophoblastic tissue.
   Technique:
4. Some infiltrate with vasopressin in order to minimise bleeding
5. linear incision is made above the ectopic pregnancy
6. Pregnacy removed
7. Bleeding point at placental bed diathermied
8. Tube can either be left open or the incision can be oversewn with fine suture material.
9. Post op - serial hcgs needed until negative.

Question 5

methotrexate management

Answer 5

folic acid antagonist
Single of serial dose.
Single lower side effects.
Up to 20% need surgical management.
80% tubal patency maintained

Question 6

Prognostic factors for medical management of ectopic being successful

Answer 6

Question 7

Expectent management of ectopic - who is it suitable for

Answer 7

bHCG <1000 (<2000)
<4cm in size, no FHR
no signs of acute bleeding or rupture
Falling levels of bHCG
= in this instance with above three - 50% with spontaneously resolve.

Question 8

Definition of PID

Answer 8

Syndrome comprising a spectrum of inflammatory disorders of the upper femal genital tract comprising one or more - endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis

Question 9

PID prevelance

Answer 9

Dropping 1990s ~10%
now approx 4-5%

Question 10

PID risk factors

Answer 10

Question 11

Micro-organisms involved in PID

Answer 11

Polymicrobial in majority of cases, usually initial infection with chlamydia or gonorrhoea leads to inflammation of upper vagina and cervix with allows other vaginal commensals to enter - E Coli, anaerobes, streptococcus - and infect the upper genital tract.

Question 12

Diagnosis of PID

Answer 12

Clinical diagnosis, low threshold of suspicion.
CDC criteria for presumptive diagnosis:
Sexually active young women + pelvic or lower abdominal pain + no other cause can be identified + one of the following:
CMT, uterine tenderness, adnexal tenderness.
Specificity can be increased with -
Temp >38.3.
Mucopurulent cervical discharge or friability.
Presence of abundant WBC on saline microscopy of vaginal fluid
Elevated CRP or ESR
Lab evidence of +ve chlamydia or gonorrhoea.

TVUS has a low sensitivity and specificity.
50-60% are asymptomatic.

Question 13

PID treatment

Answer 13

Question 14

PID long term sequelae and fertility impact (risk factors for increased fertility impact)

Answer 14

1. Inferitility
2. Ectopic pregnancy
3. Chronic pelvic pain

Risk factors for tubal infertility:
1. Late treatment (early antibiotics required to reduce risk)
2. More severe disease (30% versus 6% with mild disease)
3. Presence of tubo-ovarian abscess
4. Multiple episodes of PID (12% after one, 23% after two, 54% after 3)
4. Chlamydia seems to be worse than gonorrhoea (?subtler symptoms so later diagnosis)