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what is the definition of an ectoptic pregnancy?
a pregnancy that has implanted outside the uterine cavity
what is happening to the incidence of ectopic pregnancy and why?
incidence increasing due to rising number of cases of PID, asymptomatic chlamydial infection and more IVF
name 7 sites that an ectopic pregnancy can implant?
- 1. cervical
- 2. cornual
- 3. isthmic
- 4. ampullary
- 5. fimbrial
- 6. ovarian
- 7. abdominal: primary or secondary
what is the most common location for ectoptic pregnancy? and %
tubal 95-97%; ampullary
what is the difference between primary and secondary abdominal ectopic? which is more common
- primary: fertilised then went straight to abdomen
- secondary: in the tube then burst and into abdomen. this is more common
why do you get ectopic?
- damage to tubes or their ciliary lining
- so hinder passage of fertilised egg towards uterine cavity
what are the causes of ectopic pregnancy?
- 1. PID
- 2. tubal surgery eg sterilisation, reversal of sterilisation, previous ectopic pregnancy
- 3. péritonites or pelvis surgery in past eg appendicitis
- 4. IUCD - especially COPPER COIL in situ (mirena protects)
- 5. IVF
- 6. endometriosis
- 7. progesterone only pill (mini pill) - progesterone reduces tubal motility so fertilised egg just stays in tube and implants there. mini pill does not cause ectopic, but if woman conceives when using it - the pregnancy is more likely to be ectopic than if on no contraception at all
what Qs do you ask in history of ecoptic pregnancy?
- 1. menstrual Qs: LMP
- 2. pain: where? site correlates with site of ectopic usually, unless ruptured
- 3. bleeding - decidual reaction 'crying womb' as pregnancy is in wrong place! get brown prune juice like discharge with clots
what signs do you see OE of suspected ecoptic?
- general: pale, signs of shock
- abdo: swollen, rebound tenderness, guarding
- bimanual examination: USUALLY USS FIRST!! adnexal mass, tenderness, cervical excitation, normal size of uterus
what is the first line Ix to be done? what is likely finding in ecoptic?
- empty uterus
- adnexal mass - may locate ectopic and say if live (see fettle heart rate) or dead
- free fluid in pelvis if bleeding has occurred from ecoptic
if nothing can be seen on USS, what is the next thing to do?
- serum B-HCG to confirm pregnancy
- see if above threshold level, if not do 2 serum B-HCG 48 hours apart and see TREND
what is the trend seen in ectopics of HCG?
trend: remains the same, plateaus or SUBOPTIMAL rise or fall
how do you treat a person who is in severe acute pain and has signs of shock?
- 1. ABC, iv access, resuscitate
- 2. at same time take to theatre to stop the bleeding
- 3. LAPAROTOMY
if a patient has acute abdomen but is haemodynamically stable what to do?
in a more subacute setting what is to be done?
- 1. don't head straight to surgery
- 2. USS
if there is empty uterus on USS, how do you know it wasn't a miscarriage and was an ectopic?
- B-HCG 48 hours apart
- 1. viable pregnancy: levels DOUBLE
- 2. miscarriage: FALL significantly
- 3. ectoptic: PLATEAU or rise but not as much as double
what factors make surgical management of ectoptic more likely than expectant or medical?
- 1. severe acute pain, rupture
- 2. very high beta HCG levels (as will fail medical Rx)
- 3. size of ectopic mass > 4cm
- 4. live ectopic pregnancy
if an ectopic has occurred after IVF where the tubes are scarred, what surgery would be best?
bilateral salpingectomy - so future IVF attempts do not lead to further tubal pregnancies
what is salpingotomy?
incision may over ectopic which is removed and tube is usually allowed to heal by secondary intention
what is the medical treatment for ectopics? what are indications for medical treatment and what advice needs to be given with it?
- methotrexate: folate inhibitor - cytotoxic drug
- indications: asymptomatic, small pregnancy, tube in tact, sac < 3cm with no cardiac activity, B-HCG<3000 iU/L
what advice needs to be given after medical treatment of ectopic?
- 1. not to take folic acid
- 2. adequate contraception for at least 2 months as it is a cytotoxic drug
- 3. SE: bowel spasm and pain
- 4. avoid intercourse until B-HCG negative as may rupture with intercourse
- avoid cabbage and leak as cause more constipation
what blood tests need to be done when giving medical treatment?
- FBC as methotrexate can cause low WCC, plt, RBC
if suspect ectopic, which one blood test must be done that will need acting upon?
- Rh status
- give anti-D if Rh -ve
what is the FU after ectopic pregnancy?
- 1. serial serum B-HCG to ensure resolution or removal of all trophoblastic tissue
- 2. remember 5% of medically treated pts will need further treatment with either methotrexate or surgery
what is the prognosis after ectopic pregnancy?
- chance of repeat ectopic depends on health of remaining tubal tissue
- if conservative management - affected tube will be scarred by ectopic
- rates of ectopic future - 11% in medical treatment, 12 after conservative, 9% after salpingectomy
what is the disadvantage of salpingectomy?
chance of conception is lower
what is the treatment of cervical and intramural ectopics? and why?
- medical - methotrexate
- as surgery - too much bleeding, may need hysterectomy
what is treatment of corneal peg?
what is treatment of ovarian pregnancy?
- wedge resection of ovary
- or medical
what type of pregnancy is increasing with more IVF?
- heterotopic: both intra and extra uterine pregnancy
- as more than one embryo replaced