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Ectopic pregnancy

A review of ectopic pregnancy on A4Medicine. Deaths from ectopic pregnancy are rare now. In the UK there were 10 maternal deaths in the 3 year period between 2006-2008 ( CMACE , 2011 ).

A pregnancy outside the uterine cavity.98 % implant within the Fallopian tubes hence often used term tubal pregnancy .Rest occur in the abdomen , ovary , cervix or in a C-section scar

Epidemiology- Estimated prevalence 1-2 % globally In UK nearly 12000 diagnosed each year ( ie prevalence of 1.1 % ) More common following assisted reproduction – incidence about 4 % Mortality 0.2 % per 1000 estimated ectopic pregnancies ( ie very low )

Risk factors – Previous ectopic pregnancy Previous tubal surgery
♦ sterilization
♦ reversal of sterilization
♦ tubal reconstruction or repair H/O PID , chlamydia or gonorrhoea Current use of Cu IUD or LNG-IUS
If a pregnancy occurs there is a high risk of ectopic particularly with LNG-IUS Known tubal infertility Assisted conception Endometriosis
 Smoking Increased maternal age Multiple sexual partners

Studies have identified several risk factors however most patients presenting with ectopic pregnancy have no 
identifiable risk factor

Amenorrhoea or missed period Abdominal or pelvic pain Vaginal bleeding with or without clots .Only about 50 % present with all 3 symptoms Often asymptomatic Breast tenderness Gastrointestinal symptoms Dizziness , fainting or syncope Shoulder tip pain Urinary symptoms Passage of tissue Rectal pressure or pain on defecation Typically presents
 6-8 weeks after LMP 
but can present 
earlier or late

Differential diagnosis- Miscarriage
○ threatened – vaginal bleeding 1st 24 wks gestation
♦ inevitable – threatened + os open or products of conception seen
♦ completed Molar pregnancy Postabortion bleeding Retained products of abortion Ruptured ovarian corpus luteal cyst Pregnancy related degeneration of fibroid Ovarian torsion Salpingitis Ovarian tumour Endometrioma Non-pregnancy related causes of 
bleeding in early pregnancy. Musculoskeletal Urinary tract related Constipation Pelvic inflammatory disease Appendicitis Nephrolithiasis Bowel obstruction Adhesions Ovarian cyst
○ rupture
○ torsion
○ bleeding

Presentation – Pelvic tenderness Adnexal tenderness Abdominal tenderness.Cervical motion tenderness Rebound tenderness or peritoneal signs Pallor Abdominal distension Enlarged uterus Tachycardia or hypotension ( < 100/60 ) Shock or collapse Orthostatic hypotension

Think about offering pregnancy test even when symptoms non -specific.Presentation can resemble the common symptoms and signs of other conditions – eg GI or Urinary Tract.Examination does 
not lead to rupture
 of ectopic .Pain and abdominal tenderness OR Pelvic tenderness OR Cervical motion tenderness.Pain OR A pregnancy of 6 wks gestation or more OR A pregnancy of uncertain gestation.NICE suggests referring to EPAU only if bleeding continues after 6 wks gestation or they develop symptoms of an ectopic pregnancy Bleeding settled–> Repeat pregnancy test 7-10 days & return if +ve Negative test mean -> miscarriage Return if symptoms continue or worsen.

Urine pregnancy test High resolution transvaginal US ( TVS ) Transabdominal US Serial blood hCG Serum progesterone Blood type , Rh type antibody screen FBC , Us&Es , LFT

Complications- Tubal rupture Tubal infertility Short term SEs of Methotrexate therapy Complications related to surgery- damage to surrounding organs or vessels Recurrent ectopic pregnancy Persistent trophoblast Psychological

Terms used to define management
 Expectant- spontaneous resolution Medical- methotrexate Surgical

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