Ectopic pregnancy (Complete) Flashcards
(31 cards)
Define ectopic pregnancy
Obsteric emergency which occurs when fertilised ovum implants outisde uterine cavity
What is the incidence of ectopic preganancy?
1%
Ectopic pregancies occur most commonly in which anatomical location?
Fallopian tubes
Ectopic pregancies tend to occur during which stages of pregnancy?
Week 6-8
What are the main risk factors for ectopic pregnancy?
Pelvic inflammatory disease (PID) & previous STIs (most common)
Previous ectopic pregancy
(Suggests pre-existing tubal damage or dysfunction)
Pelvic surgery
- C-section
- Appendectomy
- Tubal surgery
Endometriosis
Assisted reproduction (e.g. IVF)
(Higher risk due to embryo manipulation and altered tubal function)
IUD in situ
(Very low-risk because it prevents pregnancy altogether but if pregnancy does occur then risk is higher)
Anything which blocks passage of ovum from ovary to uterus
What are the main clinical features of ectopic pregnancy?
Signs/Symptoms:
Pelvic pain
- Typically unilateral and on side where ectopic occurs
Shoulder tip pain
- If bleeding occurs, blood can irritate the diaphragm
Abnormal vaginal bleeding
- Missed period (typically 6-8 weeks ago)
- Intermenstrual bleeding
Haemodynamic instability
- Syncope
- Tacchycardia
Examination findings:
- Unilateral abdominal tenderness
- Cervical tenderness on bimanual examination (Chandelier sign)
What are the main featurs of pelvic pain in ectopic pregancy
Usually first symptom to present
Typically unilateral (on side where ectopic occurs)
Usually lower abdomen
Pain is usually constant
Why can ectopic pregnancy present with shoulder tip pain?
If ectopic ruptures and results in bleeding, can irritate the diaphragm leading to shoulder pain
Should suspect especially in woman who are haemodynamically unstable
What clinical features are suggestive of a ruptured ectopic?
Shoulder tip pain
Signs of haemodynamic instability (e.g. syncope, tacchycardia)
What findings on examination are suggestive of ectopic pregnancy?
Unilateral abdominal tenderness
Chandalier sign: Cervical tenderness on bimanual examination
Cervical tenderness on bimanual examination is ___ sign.
Chandalier sign
AKA cervical motion tenderness
What investigations should be considered for patients with suspected ectopic pregnancy?
Bedside:
Pregnancy test: To confirm preganacy
Basic obs: Check haemodynamic status
Bloods:
VBG: Check for raised lactate
FBC: Check for anaemia
Group and save: For blood transfusion if needed
beta-hCG: Help guide management
U&Es: Check renal function
LFTs: Check liver function
Imaging:
Transvaginal ultrasound: To locate pregnancy
What sign on transvaginal ultrasound can be seen in ectopic pregnancy?
Bagel sign
Aka tubl ring sign
What are the 3 main types of management for ectopic pregnancy depending on severity?
Expectant management: Monitor patient over 48 hours. If B-hCG levels rise again or symptoms manifest intervention is performed. (Should decerease < 50% every 48 hours).
Medical management: IM Methrotrextate
- ONLY given if patient willing to attend follow-up
Surgical management:
- Salpingectomy: first-line
- Salpingotomy
Which patients are deemed suitable for expectant management?
Size <35mm
No foetal hearbeat
hCG <1000 (or plataeu/drop in hCG levels)
Assymptomatic (or minimal symptoms)
Unruptured ectopic
How are patients undergoing expectant management monitored?
Monitored for 48 hours looking at
- hCG
- Symptoms
When is management escalated for patients currently on expectant management?
If hCG starts to rise
If patient reports development of symptoms
Which patients are deemed suitable for medical management?
Size <35mm
No foetal hearbeat
hCG <1500 IU/L
No significant pain
Unruptured ectopic
Adherence to follow-up and avoiding pregnancy
No intrauterine pregnancy
Which type of management for ectopic pregnancy is contraindicted if a patient has an ectopic and a intrauterine pregancy at the same time?
Medical management (Methotrextae)
How are patients managed medically?
Methrotrexate (one-off dose)
Follow-up monitoring (to ensure management is successful)
Methotrextae is folic acid inihibitor which terminates pregnancy
If methotrextae is unsuccessful, what is the next step in management?
Second dose
OR
Surgical management
Why are woman advised to not conceive until 3 months after taking methotrexate?
Due to risk of NTD from folic acid deficiency
Which patients are deemed suitable for surgical management?
Patient haemodynamically unstable
Patient in significant pain
> 35 mm
Foetal activity detected
hCG >5000 U/L
Patient is unable to attend follow-up
Compatible with another intrauterine pregnancy
How are patients with ectopic pregnancy surgically managed?
Salpingectomy (First-line)
Salpingotomy: For patients with only one patent fallopian tube
