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22 Cards in this Set

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What are the Sx of ectopic pregnancy
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
What are the risk factors for ectopic pregnancy?
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
What is an ectopic pregnancy?
Occurs when the developing blastocyst becomes implanted at a site other than the endometrium of the uterine cavity
What types of ectopic pregnancy are there
Fallopian tube (ampullary (70%), isthmic, fimbrial)
Ovarian
Interstitial
Abdominal
Cervical
Hysterotomy scar
Heterotopic (combination of intrauterine and ectopic pregnancy)
Findings on physical exam of ectopic pregnancy
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
DDx of ectopic pregnancy
Appendicits
UTI
kidney stones
Diverticulitis
ovarian neoplasm
endometriosis
endometritis
leiomyomas
PID
Diagnostic tests in suspected ectopic pregnancy
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)
Outcomes of an ectopic pregnancy
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
Management of ecoptic pregnancy
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
Indications for surgical therapy of ectopic pregnancy
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
Indications for medical management of ectopic pregnancy
< 3.5cm unruptured
no fetal HR
beta hCG < 5000
no hepatic/renal/haematological disease
complicance assured
able and willing to follow-up
What are the different types of miscarriages
Threatened abortion
Inevitable abortion
Complete and incomplete abortion
Missed abortion
Septic abortion
Describe threatened abortion and it's aetiology
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
Describe complete abortion
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
Describe incomplete abortion
> 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
Describe a missed abortion
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
Describe a septic abortion
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
What is the most common cause of early (0-12 weeks) spontaneous abortion
chromosomal abnormality
What are the common causes of late abortions (12-20 weeks)
preterm labour
PPROM
infection
Maternal uterine or cervical defects
trauma
maternal systemic disease
Differential diagnosis of first and second trimester bleeding
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)
What should you ask about in a history of a patient with bleeding in T1/T2
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
How common are ectopic pregnancies?
Miscarriages?
1in 90 - ectopic
1in 6 - miscarriages