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ectopic pregnancy
R-GU
34
Medical
Graduate
10/13/2010

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Term
what is an ectopic pregnancy?
Definition
extrauterine implantation of an embryo - the leading cause of life threatening morbidity in the 1st trimester
Term
where do the egg and sperm meet?
Definition
in ampulla of the fallopian tube
Term
what is a salpingectomy?
Definition
removal of the entire fallopian tube, was was done the first time in 1884 by dr. tait
Term
what is a salpingostomy?
Definition
an incision made in the fallopian tube to remove an ectopic pregnancy, as was done for the first time in 1953 by dr. stromme
Term
when was the first laparoscopic salpingectomy (tube healed on its own) performed?
Definition
1973 by dr.s shapiro and adller
Term
when was the first laparoscopic salpingotomy (sewed back together) performed?
Definition
1991 by dr. young
Term
what is the pathogenesis of ectopic pregnancy?
Definition
any event that impairs the ability of tubal transport will predispose ectopic pregnancy, which occurs when proliferating trophoblasts invade the tubal wall. this proliferation of cells extends from the luminal mucosa into the muscularis and lamina propria into the serosa and ultimately into large blood vessels of the broad ligament, (doesn't grow into the tube, grows out of the tube). bleeding ensues as the tube is distorted and the serosa stretches - causing pain. 80% of the time the embryo is abnormal and regresses and 50% of the time spontaneous tubal abortion and the ectopic pregnancy may be clinically silent. tubal rupture is associated with significant hemorrhage (and possibly death).
Term
what is the most common site of ectopic pregnancy? (*exam question*)
Definition
the *ampulla of the fallopian tube* = site of 79.6% of ectopic pregnancies, because this is where the egg and sperm first meet. the next most common: isthmus then fimbria. rare: abdomen, ovary, and cervix.
Term
what is the recurrence rate of ectopic pregnancy?
Definition
15% after the 1st and 25% after the 2nd
Term
what are the risk factors for ectopic pregnancy?
Definition
*high risk: tubal sx, tubal ligation, previous ectopic, in utero exposure to DES, use of IUD, tubal pathology, assisted reproduction (ART), and the morning after pill. *moderate risk: infertility, previous genital infections (ascending gonorrhea/chlamydia), multiple sexual partners, and salpingitis isthmica nodosa (inflammation of the tube itself). *low risk: previous pelvic infection, cigarette smoking, vaginal douching, and first intercourse @ <18 yrs.
Term
what is the classic triad associated with ectopic pregnancy?
Definition
amenorrhea, irregular vaginal bleeding, and lower abdominal pain
Term
what is the most common complaint of women w/ectopic pregnancy?
Definition
sudden severe lower abdominal pain - 90-100% of pts
Term
what can happen if rupture occurs w/ectopic pregnancy?
Definition
pain can radiate to the shoulder (b/c blood irritates the diaphragm), syncope and shock (from low blood volume)
Term
what are the signs and symptoms of ectopic pregnancy?
Definition
abdominal tenderness (90%), rebound (70%), and a tender adnexal mass in 50% of pts w/ectopic pregnancy. pelvic exam is usually non-specific.
Term
what should be in the ddx for ectopic pregnancy?
Definition
appendicitis, threatened abortion, ruptured ovarian cyst, PID (rare), salpingitis, endometritis, nephrolithiasis, ovarian torsion, and intrauterine pregnancy. alt dx/things you have to worry about: dysmenorrhea, dysfunctional uterine bleed, UTI, diverticulitis, and mesenteric lymphadenitis
Term
whats the first thing you should do in every situation?
Definition
H+P
Term
how early can ectopic pregnancy occur?
Definition
as early as 4.5 weeks gestation
Term
what are routine dx tests for ectopic pregnancy?
Definition
serial measurements of beta hCG (in normal pregnancy, beta hCG should rise at least 66% and up to 2x every 48 hrs), ultrasonography (presence of any non-cystic, extra-ovarian, adnexal mass in the absence of an intrauterine pregnancy is diagnostic of an ectopic pregnancy)
Term
what characterizes abdominal ectopic pregnancy?
Definition
risk of dying is 7.7x higher than other ectopics (due to high level of blood supply) and can be either primary: primary peritoneal implantation or secondary: aborted fallopian ectopic w/direct extension. *when diagnosed - sx is tx
Term
what characterizes cervical ectopic pregnancy?
Definition
most common predisposing factor: D&C. most common symptom: painless vaginal bleeding.
Term
what is a heterotopic pregnancy?
Definition
when a pt has one pregnancy in the uterus and one outside the tubes/uterus? it is rare and if seen likely related to the pt using ART.
Term
what are the 2 treatment pathways for ectopic pregnancy?
Definition
medical or surgical - depends on the stage of the disease and the condition of the pt @ dx.
Term
what does medical treatment of ectopic pregnancy consist of?
Definition
methotrexate (MTX), a folic acid antagonist which inhibits denovo synthesis of purines and pyrimidines - thus interfering w/DNA synthesis which trophoblasts are very vulnerable to.
Term
what characterizes pts who MTX is appropriate for?
Definition
pts need to be hemodynamically stable, the ectopic must be unruptured, the sac size has to be < 4 cm, and their beta hCH has to be less than or equal to 10,000 mIU/mL
Term
how is MTX tx for ectopic pregnancy carried out?
Definition
day 1: check beta hCG, CBC, LFTs (b/c of liver toxicity/possible leukocytosis). day 4: check beta hCG. day 7: recheck day 1 labs (make sure nothing is abnormal). from day 4 to 7, there should be a 15% drop in beta hCG - if not a re-dose is necessary. sx if pain lasting longer than 12 hrs occurs or falling hematocrit, orthostatic hypotension, or acute abdomen (signs of rupture)
Term
what are the side effects of MTX?
Definition
bone marrow suppression, hepatoxicity (most common), gastritis, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity
Term
what characterizes sx as tx for ectopic pregnancy?
Definition
sx is the definitive therapy and can be laparoscopic surgery or laparotomy (if pt hemodynamically unstable or with acute abdomen go right to to laparotomy). the procedure can then be either a salpingectomy, salpingostomy, or salpingotomy.
Term
what is the difference between salpingostomy and salpingotomy?
Definition
salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with 7-0 vicryl or similar suture
Term
how is a salpingectomy, salpingostomy, or salpingotomy decided on?
Definition
all tubal pregnancies can be treated by partial or total salpingectomy. salpingostomy/salpingotomy is only indicated when: the pt has the desire to conserve her fertility, the pt is hemodynamically stable, tubal pregnancy is accessible, the tube is unruptured and <5 cm in size and the contralateral tube is absent or damaged. *there is a fertility scoring algorithm available for this (conservative sx is to remove the tube the radical sx is to leave that tube - based on risk of recurrence).
Term
what are the only arteries which bring blood back in the direction towards the heart?
Definition
the inferior epigastrics
Term
what is a major concern w/performing a salpingectomy?
Definition
ensuring the mesosalpinx is cut - so the ovary stays.
Term
what is persistent ectopic pregnancy? tx?
Definition
a complication of salpingotomy/salpingostomy when residual tissue is left behind - do serial hCGs to make sure their beta hCG returns to zero (if it does not return to 0 and it is untreated, it could be life threatening and have hemorrhaging). tx: salpingectomy or MTX (if they are stable)
Term
salpingectomy vs. salpingostomy?
Definition
salpingostomy has a higher subsequent intrauterine pregnancy rate - but the recurrent ectopic rate is higher
Term
laparoscopy vs. laparotomy ?
Definition
in a stable pt, laparoscopic salpingostomy is tx of choice (less blood loss, decreased need for analgesia, improved post operative recovery).
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