Ectopic_Pregnancy_Investigation_and_Management_Flashcards

Question 1

Where are stable women typically investigated and managed for ectopic pregnancy?

Answer 1

In an early pregnancy assessment unit.

Question 2

Where should unstable women with suspected ectopic pregnancy be referred?

Answer 2

To the emergency department.

Question 3

What is the result of a pregnancy test in cases of ectopic pregnancy?

Answer 3

A pregnancy test will be positive.

Question 4

What is the investigation of choice for ectopic pregnancy?

Answer 4

A transvaginal ultrasound.

Question 5

What are the criteria for expectant management of ectopic pregnancy?

Answer 5

Size <35mm, unruptured, asymptomatic, no fetal heartbeat, hCG <1,000IU/L, compatible if another intrauterine pregnancy.

Question 6

What are the criteria for medical management of ectopic pregnancy?

Answer 6

Size <35mm, unruptured, no significant pain, no fetal heartbeat, hCG <1,500IU/L, not suitable if intrauterine pregnancy.

Question 7

What are the criteria for surgical management of ectopic pregnancy?

Answer 7

Size >35mm, can be ruptured, pain, visible fetal heartbeat, hCG >5,000IU/L, compatible with another intrauterine pregnancy.

Question 8

What does expectant management of ectopic pregnancy involve?

Answer 8

Closely monitoring the patient over 48 hours and intervening if B-hCG levels rise again or symptoms manifest.

Question 9

What does medical management of ectopic pregnancy involve?

Answer 9

Giving the patient methotrexate and ensuring the patient is willing to attend follow-up.

Question 10

What does surgical management of ectopic pregnancy involve?

Answer 10

Surgical management can involve salpingectomy or salpingotomy.

Question 11

What is the first-line surgical management for women with no other risk factors for infertility?

Answer 11

Salpingectomy.

Question 12

When should salpingotomy be considered for ectopic pregnancy?

Answer 12

Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage. Around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy).

Question 13

summarise

Answer 13

Ectopic pregnancy: investigation and management

Women who are stable are typically investigated and managed in an early pregnancy assessment unit. If a woman is unstable then she should be referred to the emergency department.

Investigation

A pregnancy test will be positive.

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

Question 14

An 18-year-old woman is assessed in the urgent gynaecology clinic due to concerns about her period being 3 weeks overdue. She has been experiencing mild abdominal cramping but no other symptoms.

A transvaginal ultrasound is performed and shows an adnexal mass of 28mm with no visible heartbeat, consistent with an extrauterine pregnancy.

How should this patient be managed?

Laparoscopic salpingectomy
Laparoscopic salpingotomy
Methotrexate
Mifepristone and misoprostol
Misoprostol

Answer 14

Methotrexate

Methotrexate is the drug of choice for medical management of ectopic pregnancy

Methotrexate is correct. This patient has an ultrasound-proven ectopic pregnancy which needs urgent management. As the adnexal mass is < 35mm, has no detectable heartbeat and has not ruptured, this patient can be managed medically according to NICE, as the pain they are experiencing is not severe. Methotrexate is the drug of choice to manage an ectopic pregnancy - it is highly teratogenic, so a single dose of IM methotrexate can induce spontaneous termination. It is important to discuss that methotrexate can be teratogenic up until 3 months after the treatment.

Laparoscopic salpingectomy is the choice for surgical management of an ectopic pregnancy. As this patient is currently stable and suitable for medical management, an invasive approach can be avoided. This patient is also 18 years old, therefore salvaging the fallopian tube is the most favourable outcome.

Laparoscopic salpingotomy is not the procedure of choice, even for surgical management - it is usually only reserved for patients who have had a previous salpingectomy or have significant adhesions, therefore the tube is preserved. Again, it is not indicated in this case, as medical management is more appropriate for this patient.

Mifepristone and misoprostol is incorrect. This combination of drugs is given to terminate a pregnancy, and although an ectopic pregnancy must be terminated, those are not the appropriate drugs to use. Mifepristone blocks the action of progesterone, halts the growth of pregnancy and relaxes the cervix - although stopping the growth of the pregnancy is beneficial, as the pregnancy is extrauterine it would not help with expelling it.

Misoprostol is incorrect. It is a prostaglandin analogue which stimulates uterine contractions and is used alongside mifepristone to terminate a pregnancy. As this pregnancy is extrauterine, inducing uterine contractions would not suffice in managing it.

Question 15

A 27-year-old woman has been referred to Early Pregnancy Unit, with pregnancy of unknown gestation and with some per vaginal bleeding.

She denies pain and is haemodynamically stable. This is her first pregnancy.

Ultrasound demonstrates a tubal pregnancy, with a visible foetal heartbeat and an unruptured adnexal mass of 40mm. beta-hCG is 5,200 IU/L.

What management would be first-line for this patient?

Surgical - open salpingectomy
Expectant
Medical
Reassure and do nothing
Surgical - laparoscopic salpingectomy

Answer 15

Surgical - laparoscopic salpingectomy

All ectopic pregnancies >35 mm in size or with a serum B-hCG >5,000IU/L should be managed surgically

The correct answer is:

Surgical - laparoscopic salpingectomy. Surgical management is indicated if an ectopic pregnancy is confirmed on ultrasound with an adnexal mass of 35mm or larger. In this case, the adnexal mass is 40mm. The beta-hCG is also >5,000 IU/L here. In most cases, surgery is done via laparoscopy.

The incorrect answers are:

Surgical - open salpingectomy. Laparotomy is reserved for emergency cases where there is rupture of the Fallopian tube and with haemodynamic instability. Here the patient is haemodynamically stable without rupture, so laparotomy is not required at present.

Medical. The adnexal mass is >35mm and BHCG >1500 so medical management would be inappropriate here.

Expectant. The adnexal mass is >35mm and BHCG is >1500 so medical management would be inappropriate here.

Reassure and do nothing. This is inappropriate as this patient’s ectopic pregnancy requires treatment.

Question 16

A 35-year-old woman presents to the emergency department with sudden abdominal pain and vaginal bleeding. She has a past medical history of complicated pelvic inflammatory disease resulting in scarring of the right fallopian tube. Her last period was 6 weeks ago.

Her heart rate is 93 bpm, and her blood pressure is 136/76 mmHg. Palpation of the left iliac fossa elicits pain. A urinary pregnancy test is positive and further investigations are performed:

Serum b-hCG 5200 IU/L
Ultrasound 45 mm left adnexal mass present, no heartbeat seen

What is the most appropriate step in her management?

Expectant management and monitoring
Laparoscopic salpingectomy and monitoring
Laparoscopic salpingotomy and monitoring
Methotrexate and monitoring
Vaginal misoprostol and monitoring

Answer 16

Laparoscopic salpingotomy and monitoring

Ectopic pregnancy requiring surgical management: Salpingotomy (rather than salpingectomy) should be considered for women with risk factors for infertility such as contralateral tube damage

Laparoscopic salpingotomy and monitoring is correct. This patient has acute-onset abdominal pain and vaginal bleeding after 6-8 weeks following her last period which should raise suspicion of an ectopic pregnancy. The positive pregnancy tests and ultrasound findings confirm this diagnosis. Given that the size of the ectopic pregnancy is greater than 35 mm, and the beta-hCG levels are higher than 5000 IU/L, the most appropriate step in this patient’s management is surgical, either via a laparoscopic salpingectomy (removal of the affected tube) or salpingotomy (removal of the ectopic pregnancy material and retaining the tube). The preferred method depends on the status of the other tube and the woman’s desire for future fertility. Given that she has pelvic inflammatory disease (PID) requiring hospitalisation that has led to scarring of the contralateral tube, the ideal method of choice would be a salpingotomy. This preserves the affected tube and means that her fertility is preserved.

Expectant management and monitoring is incorrect. This would be an appropriate option if the size of the ectopic pregnancy was less than 35 mm, the beta-hCG levels were less than 1000 IU/L, no foetal heartbeat was present, and the patient was asymptomatic. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making expectant management less appropriate.

Laparoscopic salpingectomy and monitoring is incorrect. Although this is another option for surgery in the management of ectopic pregnancy, it would be less appropriate to remove the affected tube in its entirety as this patient has a history of PID requiring hospitalisation and subsequent contralateral fallopian tube scarring. A salpingotomy means that the affected tube is preserved, and means that her fertility is preserved.

Methotrexate and monitoring is incorrect. This would be appropriate if the patient had no significant pain, the size of the ectopic pregnancy was <35 mm, the beta-hCG was less than 1500 IU/L, and no foetal heartbeat was present. Except for the absence of a foetal heartbeat, these do not apply to this patient, therefore making medical management with methotrexate inappropriate.

Vaginal misoprostol and monitoring is incorrect. This is used in the medical management of a miscarriage. Misoprostol is used to expedite the miscarriage. Misoprostol plays no role in the management of an ectopic pregnancy as the pregnancy tissue is not present in the uterus.

Question 17

buzz words

Answer 17

period overdue
mild abdominal cramping
adnexal mass
no visible heartbeat
extrauterine pregnancy.
pregnancy of unknown gestation
per vaginal bleeding.
very high beta-hCG
emergency department
sudden abdominal pain
vaginal bleeding
past medical history of complicated pelvic inflammatory disease resulting in scarring of the fallopian tube.
tachycardia
High BP
iliac fossa elicits pain

Question 18

salpingotomy vs salpingectomy

Answer 18

Salpingotomy: Incision and removal of an ectopic pregnancy/blockage from the fallopian tube without removing the tube; aims to preserve fertility.
Salpingectomy: Removal of one or both fallopian tubes; often done to prevent recurrence of ectopic pregnancies, for sterilization, or to reduce cancer risk; results in reduced fertility or permanent infertility if both tubes are removed.

Question 19

A 30-year-old woman presents to the Emergency Department with lower abdominal pain and vaginal bleeding. Her last menstrual period was six weeks ago. She describes the pain as sharp and localized on the right side of her abdomen. On physical examination, she appears pale but vital signs are stable. Pelvic examination reveals cervical motion tenderness.

What would be the most diagnostic investigation for this patient?

Full blood count
Serum beta-human chorionic gonadotropin (β-hCG) level
Transabdominal ultrasound
Transvaginal ultrasound
Urine pregnancy test

Answer 19

Transvaginal ultrasound

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound

The answer is a transvaginal ultrasound

In a patient with suspected ectopic pregnancy, the investigation of choice is a transvaginal ultrasound. Ectopic pregnancy is a potentially life-threatening condition where the fertilised egg implants outside the uterus, most commonly in the fallopian tube. Transvaginal ultrasound offers better visualisation and sensitivity in detecting early ectopic pregnancies compared to transabdominal ultrasound. It allows for direct visualisation of the pelvic organs, including the uterus and fallopian tubes, which can help identify an ectopic pregnancy, visualise the adnexal mass, and assess for signs of rupture or internal bleeding.

A full blood count (FBC), is a routine laboratory test that can provide information about red blood cell count, haemoglobin, and white blood cell count. While an FBC may be useful in assessing for anaemia or infection, it is not the primary investigation for evaluating a suspected ectopic pregnancy.

Measuring the serum beta-human chorionic gonadotropin (β-hCG) level is an important diagnostic test in the evaluation of pregnancy. In the context of suspected ectopic pregnancy, a rising or plateauing β-hCG level can indicate an abnormal pregnancy. However, the initial imaging modality to confirm the diagnosis and determine the location of the pregnancy is a transvaginal ultrasound.

A transabdominal ultrasound involves placing an ultrasound probe on the abdomen to obtain images of the pelvic organs. While transabdominal ultrasound can provide some information about the uterus and adnexal structures, it is less sensitive in detecting early ectopic pregnancies compared to transvaginal ultrasound. In this scenario, where there is a high suspicion of ectopic pregnancy, transvaginal ultrasound is the preferred initial imaging modality.

A urine pregnancy test, is a simple and convenient test for detecting the presence of human chorionic gonadotropin (hCG) in the urine, indicating pregnancy. However, it is not the investigation of choice for evaluating a suspected ectopic pregnancy. In this scenario, where there is a clinical suspicion of ectopic pregnancy based on the patient’s symptoms, physical examination findings, and adnexal mass, a transvaginal ultrasound is necessary for confirming the diagnosis.