Ectopic pregnancy

Obstetrics

Clinicals - History

Fact Explanation
Asymptomatic Ectopic pregnancies can be asymptomatic until either symptoms of early pregnancy or complications occur. Asymptomatic
Ectopic pregnancies can be asymptomatic until either symptoms of early pregnancy or complications occur.
Clinical triad of abdominal pain, amenorrhea, and vaginal bleeding This presentation is relatively rare. Clinical triad of abdominal pain, amenorrhea, and vaginal bleeding
This presentation is relatively rare.
Symptoms common to early pregnancy Patients may have amenorrhea, nausea, tenderness of breasts, and back pain. Symptoms common to early pregnancy
Patients may have amenorrhea, nausea, tenderness of breasts, and back pain.
Symptoms of Shock Secondary to hemorrhage caused by the rupture of the containing viscera. Symptoms of Shock
Secondary to hemorrhage caused by the rupture of the containing viscera.
Per vaginal bleeding Doesn't necessarily correlate with the severity of hemorrhage. Per vaginal bleeding
Doesn't necessarily correlate with the severity of hemorrhage.
Abdominal or pelvic pain Abdominal pain is usually colicky in type. Pelvic pain is mostly unilateral and occasionally diffused. Abdominal or pelvic pain
Abdominal pain is usually colicky in type. Pelvic pain is mostly unilateral and occasionally diffused.

Clinicals - Examination

Fact Explanation
Pelvic tenderness Due to presence of the ectopic. Pelvic tenderness
Due to presence of the ectopic.
Adnexal mass, or tenderness The ectopic may be felt as an adnexal mass. Adnexal mass, or tenderness
The ectopic may be felt as an adnexal mass.
Peritoneal signs Diffuse abdominal tenderness guarding and rigidity are indicative of ruptured ectopic. Peritoneal signs
Diffuse abdominal tenderness guarding and rigidity are indicative of ruptured ectopic.
Cervical motion tenderness This is a specific finding but not diagnostic of ectopic pregnancy. Cervical motion tenderness
This is a specific finding but not diagnostic of ectopic pregnancy.
Enlarged uterus But it is usually less than eight weeks of period of amenorrhea. Enlarged uterus
But it is usually less than eight weeks of period of amenorrhea.
Signs of shock These include tachycardia, low blood pressure, narrow pulse pressure and cold clammy extremities. Signs of shock
These include tachycardia, low blood pressure, narrow pulse pressure and cold clammy extremities.
Pulse rate Usually tachycardia is present. but maybe absent in shock following rupture Pulse rate
Usually tachycardia is present. but maybe absent in shock following rupture

Investigations - Diagnosis

Fact Explanation
Serum and urine assays for the beta subunit of human chorionic gonadotropin (bhCG) Serum and urine contains increased amounts of bhCG during pregnancy. Serum and urine assays for the beta subunit of human chorionic gonadotropin (bhCG)
Serum and urine contains increased amounts of bhCG during pregnancy.
Serum progesterone Progesterone level is lesser in an ectopic pregnancy than in a normal pregnancy. In a nonviable pregnancy or an ectopic pregnancy serum progesterone are found in lesser amounts. Serum progesterone
Progesterone level is lesser in an ectopic pregnancy than in a normal pregnancy. In a nonviable pregnancy or an ectopic pregnancy serum progesterone are found in lesser amounts.
Ultrasonography An intrauterine sack with or without fetal cardiac activity, during the scan is often adequate to exclude ectopic pregnancy. However simultaneous presence of extra-uterine and intrauterine pregnancy (Heterotrophic Pregnancy) is also a possibility. Free liquid in the pouch of Douglas is also suggestive of an ectopic pregnancy. Transvaginal ultrasonography gives higher resolution of images. Trans vaginal ultrasound when combined with serum bhCG estimation provides best way to diagnose an unruptured ectopic pregnancy. Ultrasonography
An intrauterine sack with or without fetal cardiac activity, during the scan is often adequate to exclude ectopic pregnancy. However simultaneous presence of extra-uterine and intrauterine pregnancy (Heterotrophic Pregnancy) is also a possibility. Free liquid in the pouch of Douglas is also suggestive of an ectopic pregnancy. Transvaginal ultrasonography gives higher resolution of images. Trans vaginal ultrasound when combined with serum bhCG estimation provides best way to diagnose an unruptured ectopic pregnancy.
Diagnostic dilatation and curettage The obtained curette does not show villi in an ectopic pregnancy. This is done with the purpose of diagnosis provided a non-viable pregnancy is confirmed by ultrasound scan and low level of bhCG or progesterone is present. Diagnostic dilatation and curettage
The obtained curette does not show villi in an ectopic pregnancy. This is done with the purpose of diagnosis provided a non-viable pregnancy is confirmed by ultrasound scan and low level of bhCG or progesterone is present.
Culdocentesis This method is rarely used now. A needle is inserted in to the posterior fornix and to the cul-de-sac and blood is aspirated. If the aspirated blood is not clotting it is suggestive of an ectopic pregnancy. Culdocentesis
This method is rarely used now. A needle is inserted in to the posterior fornix and to the cul-de-sac and blood is aspirated. If the aspirated blood is not clotting it is suggestive of an ectopic pregnancy.
Diagnostic laparoscopy Patients who are in pain or who are hemodynamically unstable are suitable candidates for a diagnostic laparoscopy. Once diagnosed laparoscopic salpingectomy or salpingostomy can also be done. Diagnostic laparoscopy
Patients who are in pain or who are hemodynamically unstable are suitable candidates for a diagnostic laparoscopy. Once diagnosed laparoscopic salpingectomy or salpingostomy can also be done.

Investigations - Management

Fact Explanation
Beta–human chorionic gonadotropin (β-HCG) Weekly monitoring should be done. Falling levels of β-HCG are suggestive of successful treatment or conservative management. If levels are rising even after surgical treatment methotrexate therapy can be planned as an adjunct to surgical treatment. Beta–human chorionic gonadotropin (β-HCG)
Weekly monitoring should be done. Falling levels of β-HCG are suggestive of successful treatment or conservative management. If levels are rising even after surgical treatment methotrexate therapy can be planned as an adjunct to surgical treatment.
Blood type If transfusion is needed. Blood type
If transfusion is needed.
Serum electrolytes and creatinine Renal function should be evaluated prior to the surgery Serum electrolytes and creatinine
Renal function should be evaluated prior to the surgery
Chest X-ray If there is a history of lung disease. Chest X-ray
If there is a history of lung disease.
Transvaginal ultrasound scan Screening is not recommended routinely. However in patients with risk factors (history of ectopic pregnancy, history of tubal disease or surgery, pelvic inflammatory disease) screening enables early diagnosis and intervention. Transvaginal ultrasound scan
Screening is not recommended routinely. However in patients with risk factors (history of ectopic pregnancy, history of tubal disease or surgery, pelvic inflammatory disease) screening enables early diagnosis and intervention.

Management - Specific

Fact Explanation
Expectant management Patients who are asymptomatic and without any evidence of rupture or hemodynamic instability are suitable candidates for expectant management. Serum beta–human chorionic gonadotropin levels should be assessed regularly and declining beta–human chorionic gonadotropin (β-HCG) levels suggests vanishing ectopic pregnancy. Expectant management
Patients who are asymptomatic and without any evidence of rupture or hemodynamic instability are suitable candidates for expectant management. Serum beta–human chorionic gonadotropin levels should be assessed regularly and declining beta–human chorionic gonadotropin (β-HCG) levels suggests vanishing ectopic pregnancy.
Methotrexate A chemotherapeutic agent. Patient must be hemodynamically stable, fetal cardiac activity should be absent with no evidence of tubal rupture. This is also used as an adjuvant therapy after surgery. Methotrexate
A chemotherapeutic agent. Patient must be hemodynamically stable, fetal cardiac activity should be absent with no evidence of tubal rupture. This is also used as an adjuvant therapy after surgery.
Surgical management Laparoscopic approach is preferred. Either a linear salpingostomy or salpingectomy is done. Laparotomy is preferred if the patient is hemodynamically stable. Surgical management
Laparoscopic approach is preferred. Either a linear salpingostomy or salpingectomy is done. Laparotomy is preferred if the patient is hemodynamically stable.

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