Ectopic Pregnancy
-
May be asymptomatic or
symptomatic
- May be ruptured or unruptured
Epidemiology
1) Anyone of childbearing age (10-55y)
2) Smoking
3) Previous ectopic pregnancy
4) Tubal damage (PID, chlamydia (most common), failed sterilisation)
5) Conception with failed contraception (eg. breast feeding, IUD-in situ)
6) Any previous surgeries (e.g. appendicitis → adhesions, surgery to tubes)
7) Endometriosis
8) Infertility (? ∵ salpingitis/tubal blockage), IVF
Clinical features
Symptoms
Triad:
1) Abdominal pain (>90%) – sudden onset, sharp, lower abdomen pain (early), generalised pain (ruptured)
2) Amenorrhoea (75-90%) – 5-6 weeks after normal LMP
3) PV bleeding (50-80%) – Usually spotting
Unruptured ectopic pregnancy
- Positive pregnancy test
- Afebrile(80%)
- Abdominal pain (90%)
- Rebound tenderness (45%)
- Adnexal mass on pelvic examination (50%)
- (Vaginal bleeding)
- (No gestational sac/intrauterine growth seen on TVUS)
- (Amenorrhoea)
Ruptured ectopic pregnancy
- Shock – hypovolaemia (↑ HR;↓ BP - later sign, postural drop in BP)
- Shoulder pain (phrenic nerve irritation)
- Acutely tender abdomen, guarding and rebound – surgical emergency
- Increasing, generalised abdominal pain
- Abdominal distension
- Vaginal bleeding
- No gestational sac on TVUS
- Amenorrhoea
Signs
· Rebound tenderness with small amount of guarding (Not localised)
· VE:
o Cervical excitation
o ± Adnexal mass/tenderness
o ± PV bleeding
Investigations
1. Urgent urine β-HCG (>1500-2000)
2. Urgent blood β-HCG for qualitative & quantitative β-HCG levels
3. FBC (Hb)
4. Blood group, Rhesus D, ± Crossmatch (if ruptured ectopic pregnancy)
5. Urgent transvaginal U/S (blood in ducts, adnexal mass)
- Urgent U/S if patient not shocked
- TVUS has to be interpreted in context of β-HCG
- TVUS cannot pick up pregnancy if β-HCG <2500 hence sometimes have to consider normal early pregnancy (Dr Zvi)
- Generally if β-HCG >4000, will not expect an empty uterus on TVUS (Dr Zvi)
- Note: may get completely normal U/S. Then look at β-HCG.
Management
- Admit to hospital for urgent surgical management if ruptured ectopic pregnancy
- Urgent referral to O&G
Unruptured
- Conservative: Methotrexate
- Surgery
Ruptured
- Urgent surgery
- NBM, 2x large bore cannula, IV fluids, cross-match bloods
History:
- Pc: Abdo pain, PV bleed (or "discharge")
- Likelihood of pregnancy: Intercourse
- Menstrual hx: Amenorrhoea (5-6 weeks), LMP, regular/irregular, normal duration (determine if late)
- Contraception hx - ?IUD
- Gynae hx: PID, tested for chlamydia, surg to tubes
- Obstetrics hx: ?infertility/IVF ?previous ectopic
- PMHx: any previous surgeries (pelvic/abdo)
"What possible outcomes/complications; and which will give rise to most amount of intraperitoneal bleeding?" (OSCE 1998)
- Tubal mole
- Tubal abortion
- Tubal rupture: most intraperitoneal bleed, ∵ will erode through and open up blood vessels
Source
A/Prof Amanda Dennis 2014
Dr Christine Chuter 2013
Dr Zvi Graubard 2014
- May be ruptured or unruptured
Epidemiology
1) Anyone of childbearing age (10-55y)
2) Smoking
3) Previous ectopic pregnancy
4) Tubal damage (PID, chlamydia (most common), failed sterilisation)
5) Conception with failed contraception (eg. breast feeding, IUD-in situ)
6) Any previous surgeries (e.g. appendicitis → adhesions, surgery to tubes)
7) Endometriosis
8) Infertility (? ∵ salpingitis/tubal blockage), IVF
Clinical features
Symptoms
Triad:
1) Abdominal pain (>90%) – sudden onset, sharp, lower abdomen pain (early), generalised pain (ruptured)
2) Amenorrhoea (75-90%) – 5-6 weeks after normal LMP
3) PV bleeding (50-80%) – Usually spotting
Unruptured ectopic pregnancy
- Positive pregnancy test
- Afebrile(80%)
- Abdominal pain (90%)
- Rebound tenderness (45%)
- Adnexal mass on pelvic examination (50%)
- (Vaginal bleeding)
- (No gestational sac/intrauterine growth seen on TVUS)
- (Amenorrhoea)
Ruptured ectopic pregnancy
- Shock – hypovolaemia (↑ HR;↓ BP - later sign, postural drop in BP)
- Shoulder pain (phrenic nerve irritation)
- Acutely tender abdomen, guarding and rebound – surgical emergency
- Increasing, generalised abdominal pain
- Abdominal distension
- Vaginal bleeding
- No gestational sac on TVUS
- Amenorrhoea
Signs
· Rebound tenderness with small amount of guarding (Not localised)
· VE:
o Cervical excitation
o ± Adnexal mass/tenderness
o ± PV bleeding
Investigations
1. Urgent urine β-HCG (>1500-2000)
2. Urgent blood β-HCG for qualitative & quantitative β-HCG levels
3. FBC (Hb)
4. Blood group, Rhesus D, ± Crossmatch (if ruptured ectopic pregnancy)
5. Urgent transvaginal U/S (blood in ducts, adnexal mass)
- Urgent U/S if patient not shocked
- TVUS has to be interpreted in context of β-HCG
- TVUS cannot pick up pregnancy if β-HCG <2500 hence sometimes have to consider normal early pregnancy (Dr Zvi)
- Generally if β-HCG >4000, will not expect an empty uterus on TVUS (Dr Zvi)
- Note: may get completely normal U/S. Then look at β-HCG.
Management
- Admit to hospital for urgent surgical management if ruptured ectopic pregnancy
- Urgent referral to O&G
Unruptured
- Conservative: Methotrexate
- Surgery
Ruptured
- Urgent surgery
- NBM, 2x large bore cannula, IV fluids, cross-match bloods
History:
- Pc: Abdo pain, PV bleed (or "discharge")
- Likelihood of pregnancy: Intercourse
- Menstrual hx: Amenorrhoea (5-6 weeks), LMP, regular/irregular, normal duration (determine if late)
- Contraception hx - ?IUD
- Gynae hx: PID, tested for chlamydia, surg to tubes
- Obstetrics hx: ?infertility/IVF ?previous ectopic
- PMHx: any previous surgeries (pelvic/abdo)
"What possible outcomes/complications; and which will give rise to most amount of intraperitoneal bleeding?" (OSCE 1998)
- Tubal mole
- Tubal abortion
- Tubal rupture: most intraperitoneal bleed, ∵ will erode through and open up blood vessels
Source
A/Prof Amanda Dennis 2014
Dr Christine Chuter 2013
Dr Zvi Graubard 2014