ECTOPIC PREGNANCY AND TROPHOBLASTIC DISEASE

Question 1

What are the likely sites of ectopic pregnancy?

Answer 1

Ovaries

Fimbriae of fallopian tube

Ampulla of fallopian tube

Isthmus of fallopian tube

Upper horns of the uterus - cornual ectopic

Cervix

Abdomen

Question 2

Why is the number of ectopic pregnancies rising?

Answer 2

Due to the increasing number of cases of PID and increasing number IVF users.

Question 3

What is the current incidence of ectopic pregnancies in the UK?

Answer 3

1 ectopic for every hundred term deliveries

Question 4

What are the risk factors for ectopic pregnancy?

Answer 4

PID

Tubal surgery eg sterilisation or reversal of sterilisation, previous ectopic surgery

Peritonitis or pelvic surgery eg appendicitis

IUCD in situ (coil)

IVF

Endometriosis

Progesterone only pill - if patient does conceive while on the mini pill then they are more at risk of ectopic.

Question 5

What are the symptoms of ectopic pregnancy?

Answer 5

Abdominal pain

Bleeding - if ruptured

Shoulder tip pain

Pain when going to the loo

Nausea and diarrhoea

Missed period

Positive pregnancy test

Question 6

What investigations should be done for someone with acute abdominal pain and bleeding in whom you suspect an ectopic pregnancy?

Answer 6

FBC

Serum hCG

Ultrasound - to demonstrate an empty uterus

Laparoscopy - once haemodynamically stable

Question 7

How might serum hCG help with the differential diagnosis of vaginal bleeding in a pregnant woman?

Answer 7

Two serum hCG tests should be performed 48 hours apart

A viable pregnancy will show a rise in hCG

A miscarriage will show a fall in hCG

An ectopic will show a plateau in the levels of hCG

Question 8

How do we manage patients with ectopic pregnancy?

Answer 8

Surgically - either salpingectomy (removal of the affected fallopian tube and ovary) or salpingotomy (removal of the ectopic pregnancy from the fallopian tube.

Medical treatment - cytotoxics such as methotrexate are increasingly being used (they are often delivered by injection straight into the site during laparoscopy). Used also in cases where ectopic pregnancy is located in cervix or intramurally.

Question 9

What conditions must be met for medical (rather than surgical) treatment of ectopic pregnancy to be considered?

Answer 9

Asymptomatic

Small pregnancy - less than 3 cm measured on USS

Intact tubal

No cardiac activity

hCG less than 3000 iu/L

Question 10

How do we follow up patients who have been treated for ectopic pregnancy?

Answer 10

Serum hCG must be checked at various points over the following days to make sure there is a downward trend.

Question 11

What are the complications of treatment for ovarian ectopic pregnancy?

Answer 11

Recurrence if management was conservative (ie not salpingectomy)

Lower chance of conception with salpingectomy)

Question 12

What are the complications of untreated ectopic pregnancy?

Answer 12

Fallopian rupture and massive haemorrhage

Question 13

What is a heterotopic pregnancy?

Answer 13

The extremely rare combination of intra- and extrauterine pregnancy. It is actually becoming more common because of IVF treatment. It is treated surgically through laparoscopy, avoiding instrumentation of the uterus.

Question 14

What is gestational trophoblastic disease?

Answer 14

Gestational trophoblastic disease (GTD) is a group of conditions in which tumors grow inside a woman’s uterus (womb). The abnormal cells start in the tissue that would normally become the placenta.

Question 15

What are the three main types of gestational trophoblastic disease?

Answer 15

Complete hydatidiform mole

Partial hydatidiform mole

Choriocarcinoma

Question 16

What is complete hydatidiform mole, one of the gestational trophoblastic diseases?

Answer 16

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin.

Question 17

What are the features of complete hydatidiform molar pregnancy?

Answer 17

Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy e.g. hyperemesis
Uterus large for weeks of gestation
Very high serum levels of human chorionic gonadotropin (hCG)
Hypertension
Features of hyperthyroidism

Question 18

Why are features of hyperthyroidism seen in complete hydatidiform molar pregnancy?

Answer 18

hCG can mimic thyroid-stimulating hormone (TSH) at the very high levels seen in complete hydatidiform molar pregnancy.

Question 19

What investigations would be performed in someone with suspected complete hydatidiform molar pregnancy?

Answer 19

Serum hCG

Ultrasound

Question 20

What would be seen on ultrasound of someone with complete hydatidiform molar pregnancy?

Answer 20

Molar pregnancy has a characteristic ‘bunches of grapes’ appearance on ultrasound.

Question 21

How do we treat women with complete hydatidiform molar pregnancy?

Answer 21

Urgent referral to specialist centre

Evacuation of the uterus is performed

Effective contraception is recommended to avoid pregnancy in the next 12 months

Question 22

What is partial hydatidiform molar pregnancy?

Answer 22

This is when a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY.

Question 23

What are the complications of hydatidiform molar pregnancy?

Answer 23

Choriocarcinoma
Preeclampsia
Thyroid problems
Molar pregnancy that continues or comes back

Question 24

What percentage of complete hydatidiform molar pregnancies go on to develop choriocarcinoma?

Answer 24

2-3%

Question 25

Where do metastases of choriocarcinoma usually go?

Answer 25

Lung
Liver
Brain