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22 Cards in this Set
- Front
- Back
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What are the Sx of ectopic pregnancy
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Classic
Abdominal pain (tenderness and rebound) Amenorrhea Vaginal bleeding NB: only 50% of patients present typically Some are asymptomatic and are picked up via US If present with rupture - acute onset abdominal pain, shock, vaginal bleeding |
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What are the risk factors for ectopic pregnancy?
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Prevoius ectopic pregnancy (part. women who had conservative Rx)
Tubal pathology and surgery (infection, surgyer, congenital anomalies, tumours) Intrauterin contraceptive devices Previous genital infections Infertility Multiple sexual partners (risk of PID) Smoking IVF Vaginal douching Young age < 18 |
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What is an ectopic pregnancy?
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Occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity
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What types of ectopic pregnancy are there
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Fallopian tube (ampullary (70%), isthmic, fimbrial)
Ovarian Interstitial Abdominal Cervical Hysterotomy scar Heterotopic (combination of intrauterine and ectopic pregnancy) |
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Findings on physical exam of ectopic pregnancy
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low grade fever
Abdominal tenderness and rebound adnexal, cervical motion tenderness Palpable adnexal mass (half have contralateral mass due to lutein cyst) Can be often unremarkable with a small, unruptured ectopic pregnancy |
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DDx of ectopic pregnancy
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Appendicits
UTI kidney stones Diverticulitis ovarian neoplasm endometriosis endometritis leiomyomas PID |
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Diagnostic tests in suspected ectopic pregnancy
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hCG
Mean doubling time 1.4-2.1 days in early pregnancy Rises at a slower rate with ectopic Transvaginal US - detect presence (or absence) of a pregnancy within or outside of the uterus Discriminatory zone = serum hCG level above which a gestational sac should be visualised by US examination if an intrauterine pregnancy is present (1500 or 2000 IU/L with TVS; or > 6000 transabdominal) Absence of intrauterine gestational sac at hCG concentrations above the discriminatory zone strongly suggests an ectopic pregnancy Below discriminatory zone could be early viable intrauterine pregnancy or an ecoptic Laparoscopy (definitive diagnosis) |
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Outcomes of an ectopic pregnancy
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Tubal rupture --> profound haemorrhage
Tubal abortion - expulsion of the products of conception through the fimbria (can be followed by an abdominal or ovarian pregnancy) Spontaneous resolution |
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Management of ecoptic pregnancy
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Watch and wait - minimal sx, stable, low HCG or decreasing HCG
Surgical - salpingostomy (incision into tube and removal of gestational sac) or salpingectomy (removal of tube) Medical - methotrexate - single IM or IV dose - monitor Day 1, Day 4, Day 7 - HCG should be less than Day 4 peak - if not give another dose of methotrexate |
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Indications for surgical therapy of ectopic pregnancy
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haemodynamic instability
impending or ongoing ectorpic mass rupture failed medical therapy or lack of compliance hCG > 5000 mIU/ml - more likely to experience failure with methotrexate fetal heart rate hepatic/renal/haematological disease poor compliance unable to follow-up |
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Indications for medical management of ectopic pregnancy
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< 3.5cm unruptured
no fetal HR beta hCG < 5000 no hepatic/renal/haematological disease complicance assured able and willing to follow-up |
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What are the different types of miscarriages
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Threatened abortion
Inevitable abortion Complete and incomplete abortion Missed abortion Septic abortion |
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Describe threatened abortion and it's aetiology
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Bleeding through a closed cervical os in the first half of pregnancy
Generally painless, may be accompanied by minimal/mild suprapubic pain Exact aetiology often cannot be determined - frequently attributed to marginal separation of the placenta |
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Describe complete abortion
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Abortion that occurs < 12 weeks GA
Entire contents of the uterus are expelled Uterus is small and well contracted, closed cervix, scant vaginal bleeding, mild cramping Accounts for 1/3 of cases |
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Describe incomplete abortion
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> 12 weeks GA
Membranes rupture, fetus passed, significant amounts of placental tissue may be retained Cervical os is open, gestational tissue may be observed in the vagina/cervix, uterine size is smaller, not well contracted, painful cramps, variable bleeding |
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Describe a missed abortion
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A missed abortion refers to in-utero death of the embryo or fetus prior to the 20th week of gestation with retention of the pregnancy for a prolonged period of time
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Describe a septic abortion
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Features of sepsis with lower abdominal tenderness, a boggy, tender uterus with dilated cervix + abortion
Usually due to S. aureus, gram -ve bacilli or some gram +ve cocci Common complaint of illegal abortion, foreign bodies (IUD), invasive procedure (amniocentesis, CVS), maternal bacteraemia, incomplete spontaneous or legally induced abortion |
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What is the most common cause of early (0-12 weeks) spontaneous abortion
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chromosomal abnormality
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What are the common causes of late abortions (12-20 weeks)
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preterm labour
PPROM infection Maternal uterine or cervical defects trauma maternal systemic disease |
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Differential diagnosis of first and second trimester bleeding
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Physiologic bleeding = spotting due to implantation of placenta - reassure and check serial beta hCGs
abortion Abnormal pregnancy (ectopic, molar) Trauma (post-coital) Genital lesion (e.g., cervical polyp, neoplasms) |
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What should you ask about in a history of a patient with bleeding in T1/T2
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Characteristics of the bleeding (including any tissue passed)
Pain (cramping suggests SA) Risk factors for ectopic pregnancy Previous spontaneous abortion Recent trauma History of coagulopathy Gynae/obs Hx Dizziness (significant blood loss may be associated with ruptured ectopic) Fever |
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How common are ectopic pregnancies?
Miscarriages? |
1in 90 - ectopic
1in 6 - miscarriages |
