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21570957962265In Preg-nancy00In Preg-nancy27787607962265TVUS: discriminatory zone beta-hCG >1500-2400 (ie. >4.5/40) 5/40 = beta-hCG >15 = gestational sac (= 1/52 after missed period) 5.5/40 = beta-hCG 2500-5000 = yolk sac 6/40 = beta-hCG 5000-17000 = fetal pole and cardiac activity Gestational sac >5mm + yolk sac / fetal pole / double decidual sac signTAUS: discriminatory zone beta-hCG >3000-6000 = TAUS (lag behind TVUS by 1/52) If >6/40 and IUP with fetal heart beat seen discharge with early pregnancy clinic follow up If >6/40 and no IUP seen formal TVUS 5/40 = gestational sac 6/40 = yolk sac 7/40 = fetal heart Pros: non-invasive; less expertise required Cons: less sensitive than TVUS00TVUS: discriminatory zone beta-hCG >1500-2400 (ie. >4.5/40) 5/40 = beta-hCG >15 = gestational sac (= 1/52 after missed period) 5.5/40 = beta-hCG 2500-5000 = yolk sac 6/40 = beta-hCG 5000-17000 = fetal pole and cardiac activity Gestational sac >5mm + yolk sac / fetal pole / double decidual sac signTAUS: discriminatory zone beta-hCG >3000-6000 = TAUS (lag behind TVUS by 1/52) If >6/40 and IUP with fetal heart beat seen discharge with early pregnancy clinic follow up If >6/40 and no IUP seen formal TVUS 5/40 = gestational sac 6/40 = yolk sac 7/40 = fetal heart Pros: non-invasive; less expertise required Cons: less sensitive than TVUS21570954911090Urine: urine = plasma concentration in normal hydrated patient; urine false negative rate <1%; false negative in dilute urine / early pregnancy; low false positive rate; can detect from beta-hCG 25iu/L; not helpful in ectopic; should do quantitative level (ie. Plasma) in ?ectopic; will remain positive for 2-3/52 after surgery for ectopic, but should be <20 after 2/52; level may continue to ? for 3/7 after methotrexate Home pregnancy test: detects beta-hCG >500; positive by 4/40; sensitivity 50%, specificity 77-94%Serum: Should ? 1.6-2x per 48hrs (? exponentially) in 1st 6/40 plateau at 10-12/40 ? at 12/40; elimination half life 9hrs; positive within few days of conception; linear ? in ectopic Beta-hCG ? >50% in 2/7 suggests viable pregnancy ? <50% in 2/7 suggests ectopic ? <35% in 2/7 suggests ectopic ? >35% in 2/7 suggests miscarriageProgesterone level: produced by corpus luteum in viable pregnancy; distinguishes IUP from ectopic/miscarriage; <16nmol/L = 100% sensitivity for non-viable pregnancy00Urine: urine = plasma concentration in normal hydrated patient; urine false negative rate <1%; false negative in dilute urine / early pregnancy; low false positive rate; can detect from beta-hCG 25iu/L; not helpful in ectopic; should do quantitative level (ie. Plasma) in ?ectopic; will remain positive for 2-3/52 after surgery for ectopic, but should be <20 after 2/52; level may continue to ? for 3/7 after methotrexate Home pregnancy test: detects beta-hCG >500; positive by 4/40; sensitivity 50%, specificity 77-94%Serum: Should ? 1.6-2x per 48hrs (? exponentially) in 1st 6/40 plateau at 10-12/40 ? at 12/40; elimination half life 9hrs; positive within few days of conception; linear ? in ectopic Beta-hCG ? >50% in 2/7 suggests viable pregnancy ? <50% in 2/7 suggests ectopic ? <35% in 2/7 suggests ectopic ? >35% in 2/7 suggests miscarriageProgesterone level: produced by corpus luteum in viable pregnancy; distinguishes IUP from ectopic/miscarriage; <16nmol/L = 100% sensitivity for non-viable pregnancy2438404911725Investigation00Investigation15513057189470USS00USS8890049955440015513054911090Beta-hCG00Beta-hCG15513053752850History: 90% abdominal pain (highest sensitivity), 50% irregular PV bleeding (usually 4-12/52 amenorrhoea); pain, no PV bleeding in 10%; no PV bleeding or pain in 10%; shoulder tip pain = rupture; syncope; PV bleeding + pain = ectopic pregnancy until proven otherwiseExamination: 75% abnormal abdominal mass; 50% adnexal mass; 30% uterine enlargement; relative bradycardia common80% patient with PV bleeding + pain + adnexal mass do not have ectopic00History: 90% abdominal pain (highest sensitivity), 50% irregular PV bleeding (usually 4-12/52 amenorrhoea); pain, no PV bleeding in 10%; no PV bleeding or pain in 10%; shoulder tip pain = rupture; syncope; PV bleeding + pain = ectopic pregnancy until proven otherwiseExamination: 75% abnormal abdominal mass; 50% adnexal mass; 30% uterine enlargement; relative bradycardia common80% patient with PV bleeding + pain + adnexal mass do not have ectopic2438403752850Assessment00Assessment2463802762885Risk Factors00Risk Factors15513052760980Previous tubal STD / surgery, old mum, endometriosis / atropic endometrium, abnormal anatomy, IUD / assisted reproduction, smoking, OCP (especially progestrogen only eg. Norethisterone). Family history is NOT a risk factor (according to MCQ).For heterotropic pregnancy: use of follicular stimulation (1:100-500), PID, IUCD, tubal surgery, assisted r reproduction00Previous tubal STD / surgery, old mum, endometriosis / atropic endometrium, abnormal anatomy, IUD / assisted reproduction, smoking, OCP (especially progestrogen only eg. Norethisterone). Family history is NOT a risk factor (according to MCQ).For heterotropic pregnancy: use of follicular stimulation (1:100-500), PID, IUCD, tubal surgery, assisted r reproduction2463801818005Epidemiology00Epidemiology15513051818005Leading cause of maternal death in 1st trimester (10%); occurs in 2% pregnancies (10/1000); incidence in standard population 20/1000; 60% women with ectopic pregnancy will conceive naturally again 25- 30% ectopic pregnancy rate in subsequent pregnancies80% ampullary, 10% isthmic, 6% fimbrial, 1.5% cornual, 1.5% abdominal (usually from ruptured tubal ectopic), 0.2% ovarian, 0.2% cervical00Leading cause of maternal death in 1st trimester (10%); occurs in 2% pregnancies (10/1000); incidence in standard population 20/1000; 60% women with ectopic pregnancy will conceive naturally again 25- 30% ectopic pregnancy rate in subsequent pregnancies80% ampullary, 10% isthmic, 6% fimbrial, 1.5% cornual, 1.5% abdominal (usually from ruptured tubal ectopic), 0.2% ovarian, 0.2% cervical243840845185Definition00Definition1551305843915Implantation of fertilised ovum in any location other than endometriumCornual (interstitial) pregnancy: 0.4-4% ectopic pregnancies; uterine rupture early in pregnancy severe haemorrhage, high morbidity and mortalityHeterotropic pregnancy: IUP + ectopic; incidence 1:4000 pregnancies; if find IUP on USS, ectopic virtually excluded unless specific risk factor for it00Implantation of fertilised ovum in any location other than endometriumCornual (interstitial) pregnancy: 0.4-4% ectopic pregnancies; uterine rupture early in pregnancy severe haemorrhage, high morbidity and mortalityHeterotropic pregnancy: IUP + ectopic; incidence 1:4000 pregnancies; if find IUP on USS, ectopic virtually excluded unless specific risk factor for it246380211455Ectopic Pregnancy00Ectopic Pregnancy134620437515002209802683510Treatment00Treatment15284452682240Indications for conservative treatment (observation): beta-hCG <1000 and fallingIndications for surgery: cardiovascular instability, cervical pregnancy, ectopic fetal heart activity, >100ml free fluid in Pouch of DouglasIndications for salpingectomy: severe tubal damage, uncontrolled bleeding, recurrent ectopics of same tube, tubal pregnancy >5cmIndications for salpingotomy and salpingostomy: unruptured tubal pregnancy <4cm Methotrexate: inhibits cell division in rapidly growing tissues Indications: asymptomatic, high compliance, beta-hCG <3500, tubal size <3cm, no fetal heart activity on TVUS; 87% success rate single dose, 95% success rate multiple dose (give if beta-hCG day 7 > day 4; required in 10%) Side effects = stomatitis, photosens, impaired LFTs, gastritis, bone marrow suppression, alopecia, fever. Risk of rupture so review if abdominal pain. Rh prophylaxis: 250-625iu IM00Indications for conservative treatment (observation): beta-hCG <1000 and fallingIndications for surgery: cardiovascular instability, cervical pregnancy, ectopic fetal heart activity, >100ml free fluid in Pouch of DouglasIndications for salpingectomy: severe tubal damage, uncontrolled bleeding, recurrent ectopics of same tube, tubal pregnancy >5cmIndications for salpingotomy and salpingostomy: unruptured tubal pregnancy <4cm Methotrexate: inhibits cell division in rapidly growing tissues Indications: asymptomatic, high compliance, beta-hCG <3500, tubal size <3cm, no fetal heart activity on TVUS; 87% success rate single dose, 95% success rate multiple dose (give if beta-hCG day 7 > day 4; required in 10%) Side effects = stomatitis, photosens, impaired LFTs, gastritis, bone marrow suppression, alopecia, fever. Risk of rupture so review if abdominal pain. Rh prophylaxis: 250-625iu IM220980437515Investigation(cntd)00Investigation(cntd)15513051697355If beta-hCG above discriminatory zone (>2000) and no IUP, or mass in ovary / tube = likely ectopic (90% PPV)If beta-hCG >6500 and no fetal heart seen on USS = 80% chance of miscarriageIf beta-hCG below discriminatory zone (<2000) and inconclusive scan = pregnancy unknown location 48hr follow up (serial beta-hCG’s or repeat USS)00If beta-hCG above discriminatory zone (>2000) and no IUP, or mass in ovary / tube = likely ectopic (90% PPV)If beta-hCG >6500 and no fetal heart seen on USS = 80% chance of miscarriageIf beta-hCG below discriminatory zone (<2000) and inconclusive scan = pregnancy unknown location 48hr follow up (serial beta-hCG’s or repeat USS)1551305437515USS00USS2160905437515In Ecto-pic00In Ecto-pic2778760437515Will be indeterminate in 15%Findings: empty uterus (25% have ectopic, LR 2.2), tubal ring outside uterus, extrauterine mass +/- cardiac activity, interstitial / heterotropic pregnancy, extrauterine empty gestational sac, free fluid (in pouch of Douglas 70% sensitivity and specificity for ectopic; large amount 50% sensitivity, 95% specificity), nonspecific anechoic intrauterine fluid collections (3% have ectopic, LR 1)00Will be indeterminate in 15%Findings: empty uterus (25% have ectopic, LR 2.2), tubal ring outside uterus, extrauterine mass +/- cardiac activity, interstitial / heterotropic pregnancy, extrauterine empty gestational sac, free fluid (in pouch of Douglas 70% sensitivity and specificity for ectopic; large amount 50% sensitivity, 95% specificity), nonspecific anechoic intrauterine fluid collections (3% have ectopic, LR 1) ................
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