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what is the definition of an ectoptic pregnancy?
a pregnancy that has implanted outside the uterine cavity
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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
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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
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what is the most common location for ectoptic pregnancy? and %
tubal 95-97%; ampullary
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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
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why do you get ectopic?
- damage to tubes or their ciliary lining
- so hinder passage of fertilised egg towards uterine cavity
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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
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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
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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
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what is the first line Ix to be done? what is likely finding in ecoptic?
- USS
- 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
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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
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what is the trend seen in ectopics of HCG?
trend: remains the same, plateaus or SUBOPTIMAL rise or fall
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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
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if a patient has acute abdomen but is haemodynamically stable what to do?
LAPAROSCOPY
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in a more subacute setting what is to be done?
- 1. don't head straight to surgery
- 2. USS
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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
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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
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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
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what is salpingotomy?
incision may over ectopic which is removed and tube is usually allowed to heal by secondary intention
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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
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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
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what blood tests need to be done when giving medical treatment?
- FBC as methotrexate can cause low WCC, plt, RBC
- U&E
- LFT
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if suspect ectopic, which one blood test must be done that will need acting upon?
- Rh status
- give anti-D if Rh -ve
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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
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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
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what is the disadvantage of salpingectomy?
chance of conception is lower
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what is the treatment of cervical and intramural ectopics? and why?
- medical - methotrexate
- as surgery - too much bleeding, may need hysterectomy
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what is treatment of corneal peg?
surgery
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what is treatment of ovarian pregnancy?
- wedge resection of ovary
- or medical
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what type of pregnancy is increasing with more IVF?
- heterotopic: both intra and extra uterine pregnancy
- as more than one embryo replaced
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