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Ectopic Pregnancy

An ectopic pregnancy is the implantation of a pregnancy outside the endometrial cavity. 98% occur in fallopian tubes, but it can also occur in the interstitium, ovaries, cervix, and abdomen.

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“Ectopic Pregnancy” © BruceBlaus CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/)

Risk factors - PID, Endometriosis, Previous ectopic, Previous pelvic (esp. tubal) surgery IVF, Pregnant with IUCD/Sterilisation/POP


Presentation

  • Abdominal pain

  • PV Bleeding

    • Pain comes before the bleeding, which differentiates it from a miscarriage


The main complication here is rupture, which will present with shoulder pain as the blood leaks into the peritoneum and irritates the diaphragm.


Investigations

  • Pregnancy test

  • TVUS – Free peritoneal fluid, Sac w/o foetus, Tubal ring sign

  • Laparoscopy is done for a definitive diagnosis


N.B. Shouldn't manually examine the patient as it could increase the risk of rupture.

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“An ectopic pregnancy adjacent to the left ovary. Note the gestational sac.” © James Heilman, MD CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/) “Laparoscopic view, looking from superiorly to inferiorly in the peritoneal cavity which has been pumped up with carbon dioxide gas to visualize the uterus (marked by blue arrows). On the left Fallopian tube there is an ectopic pregnancy and hematosalpinx (marked by red arrows). The right tube is normal.” © Mikael Häggström CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0/)

If nothing is seen/confirmed on TVUS, it's deemed to be a Pregnancy of Unknown Location i.e. could be an ectopic pregnancy or very early intrauterine pregnancy that’s too small to see. If the patient is systemically well with minimal pain, monitor b-HCG every 48 hrs:

  • Fall = foetus won’t develop, or there has been a miscarriage

  • Slight increase = likely ectopic pregnancy

  • Normal increase = foetus growing normally (doesn’t exclude ectopic, but makes it less likely)


N.B. An intrauterine pregnancy should be seen by 5 weeks after LMP.


Management

Medical - Methotrexate


N.B. Methotrexate is contraindicated when a foetal heartbeat is detected due to an increased rate of treatment failure.


Surgical - Salpingectomy or Salpingotomy

  • Salpingotomy is an option if the patient has only 1 functioning tube or they still want to have children in the future

  • Salpingotomy carries the risk that not all tissue has been removed


Expectant - Waiting for ectopic to resolve on its own



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