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ECTOPIC PREGNANCY

DEFINITION

Occurs when the developing blastocyst becomes impanted at a site other


than the endometrium of the uterine cavity. The most common site is
fallopian tube (91% - 95%). Other locations are caesarean scar, cervix and
abdomen.

Risk factors

1. Previous ectopic pregnancy


2. Previous tubal surgery
3. Failed tubal ligation
4. Documented tubal damage or pathology
5. Failed IUCD
6. History of infertility
7. Previous pelvic/ genital infection
8. Multiple sexual partners
9. ART
10. Cigarette smoking

SYMPTOMS AND SIGNS

- Can be presented with variety of symptoms


- The typical triad of symptoms are
1. Bleeding
2. Abdominal pain
3. amenorrhoea
- Be aware that atypical presentation for atopic pregnancy is common

SYMPTOMS SIGNS

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1. Abdominal or pelvic pain 1. Pelvic tenderness
2. Amenorrhea or missed period 2. Adnexal tenderness
3. Vaginal bleeding with or 3. Abdominal tenderness
without clots 4. Other:
4. Other: - Cervical motion tenderness
- Breast tenderness - Rebound tenderness
- Gastrointestinal symptoms - Pallor
- Dizziness, fainting or syncope - Abdominal distension
- Shoulder tip pain - Enlarged uterus
- Urinary symptoms - Tachycardia
- Passage of tissue - Shock or collapse
- Rectal pressure or pain on - Orthostatic hypotension
defaecation

DIAGNOSIS OF VIABLE INTRAUTERINE PREGNANCY AND OF


ECTOPIC PREGNANCY

Using ultrasound for diagnosis

- Offer women who attend an early pregnancy assessment service a


TVS to identify location of the pregnancy and whether there is fetal
pole and heartbeat.
- The most appropriate diagnostic criteria include combination of
1. Positive pregnancy test
2. Empty intrauterine cavity
3. Complex adnexal mass +/- extrauterine gestation sac
- Other ultrasound features
1. Pelvic free fluid
2. Bagel signs (a fluid filled adnexal mass surrounded by
hyperechogenic ring)
3. Pseudosac
- When diagnosing complete miscarriage on an ultrasound scan in the
absence of a previous scan confirming an intrauterine pregnancy
always be aware of the possibility of extopic pregnancy
- Be aware that women with a pregnancy of unknown location could
have an ectopic pregnancy until the location is determined

Serum hCG level


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- An increase in serum hCG greater than 63% after 48 hours
1. Likely intrauterine pregnancy
2. For TVS to determine location of the pregnancy between 7-14
days later. Consider early scan if hCG level more or equal to
1500 IU/litre
 If viable intrauterine – continue ANC care
 Intrauterine pregnancy not confirmed – for assessment by
specialist
- Decrease greater than 50% after 48 hours
1. Failing pregnancy
2. Repeat UPT 14 days after the second serum hCG test
 Negative – no further action
 Positive – return to EPAU
- In a woman with a pregnancy of unknown location, place more
importance on clinical symptoms than on serum hCG results, and
review the woman’s condition if any of her symptoms change
regardless of previous results and assessments.
- Regardless of serum hCG levels, give women with pregnancy of
unknown location written information about what to do if they
experience any new or worsening symptoms. Advice women to return
if there are new symptoms or if existing symptoms worsen.

Surgical Management

1. Removal of tubal ectopic pregnancy can be done laparoscopically, in


the case of rupture patient hemodynamically unstable, a laparotomy
may be needed to expedite the procedure and control bleeding.
2. Options
- Salpingectomy – if fertility is not desired, recurrent ipsilateral
ectopic pregnancy or uncontrolled bleeding
- Linear salpingostomy

Medical Management

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1. Early diagnosis of ectopic pregnancy allows for medical management
in appropriate candidates
2. MTX can considered in
- Confirmed or presumed ectopic pregnancy
- Hemodynamically stable
- Unruptured mass with an adnexal mass smaller than 35mm
with no visible heartbeat
3. Success with MTX is >90% when initial hCG level is <5000mIU/ml

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