Ectopic Pregnancy Management Quiz
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Questions and Answers

What indicates successful medical therapy for ectopic pregnancies?

  • Increase in hCG levels
  • No change in hCG levels
  • Fall in hCG of ≥15% (correct)
  • Fall in hCG of ≥10%

    • A fall in hCG levels of less than 15% confirms the success of medical therapy for ectopic pregnancies.

    False

    What is the significance of monitoring hCG levels in management of ectopic pregnancies?

    It helps determine the success of medical therapy.

    A fall in hCG levels of ________% or more indicates successful medical therapy for ectopic pregnancy.

    <p>15</p> Signup and view all the answers

    Match the following terms related to ectopic pregnancy management with their descriptions:

    <p>Fall in hCG ≥15% = Successful medical therapy Fall in hCG &lt;15% = Unsuccessful medical therapy Regular monitoring = Assessment of treatment effectiveness Ectopic pregnancy = Implantation outside of the uterus</p> Signup and view all the answers

    What is considered the gold standard for assessing obstetric complications?

    <p>Laparoscopy</p> Signup and view all the answers

    A serum progesterone level of ≥25ng/mL indicates a live intrauterine pregnancy.

    <p>True</p> Signup and view all the answers

    What progesterone level is indicative of a live intrauterine pregnancy?

    <p>≥25ng/mL</p> Signup and view all the answers

    The procedure considered a gold standard for obstetric complications is __________.

    <p>laparoscopy</p> Signup and view all the answers

    Match the following tests with their purpose in obstetrics:

    <p>Laparoscopy = Investigative procedure for complications Serum progesterone = Determining viability of pregnancy Ultrasound = Visual imaging of the fetus MRI = Detailed imaging for complex cases</p> Signup and view all the answers

    Which part of the Fallopian tube is the most common site for ectopic pregnancy?

    <p>Ampulla</p> Signup and view all the answers

    Progesterone levels during an ectopic pregnancy are higher than in a non-pregnant state.

    <p>True</p> Signup and view all the answers

    What is the duration of an ectopic pregnancy that occurs in the interstitium?

    <p>Lasts longest</p> Signup and view all the answers

    The __________ is the narrowest part of the Fallopian tube.

    <p>Interstitium</p> Signup and view all the answers

    Match the following sites of ectopic pregnancy with their commonality:

    <p>Fallopian Tube = Most common Ovary = Most common non-tubal site C-section scar = Least common Cervical ectopic = Less common than tubal</p> Signup and view all the answers

    What is one of the most specific symptoms of ectopic pregnancy?

    <p>Pain abdomen</p> Signup and view all the answers

    The urge to defecate is a symptom only associated with ruptured ectopic pregnancies.

    <p>True</p> Signup and view all the answers

    What is the common triad of symptoms in ectopic pregnancies?

    <p>Amenorrhea, pain abdomen, bleeding p/v</p> Signup and view all the answers

    For an ectopic pregnancy located at the isthmus, termination is recommended at _____ weeks.

    <p>6-8</p> Signup and view all the answers

    Match the symptoms suggestive of ruptured ectopic pregnancy with their corresponding descriptions:

    <p>Shoulder tip pain = Referred pain from irritation of the diaphragm Urge to defecate = Indicates blood in the rectum from cul-de-sac irritation Orthostatic hypotension = Indicates possible hypovolemia from hemorrhage</p> Signup and view all the answers

    What is the first step in the investigation of suspected ectopic pregnancy?

    <p>Ultrasound Pregnancy Test (UPT)</p> Signup and view all the answers

    The presence of a gestational sac and yolk sac in the fallopian tube indicates a ruptured ectopic pregnancy.

    <p>False</p> Signup and view all the answers

    What critical ß hCG value is associated with an unruptured ectopic pregnancy when no gestational sac is visible?

    <p>≥2000 IU</p> Signup and view all the answers

    The sign indicating increased vascularity around the ectopic tissue is known as the ______ sign.

    <p>Ring of fire</p> Signup and view all the answers

    Match the following signs with their descriptions in the context of ectopic pregnancy:

    <p>Tubal sign/Bagel sign = Indicates the presence of the fallopian tube Empty uterus = Absence of intrauterine pregnancy Complex adnexal mass = Most common indication, often due to hemorrhage Ring of fire sign = Increased vascularity around ectopic tissue</p> Signup and view all the answers

    What is the most common site for tubal abortion?

    <p>Ampulla</p> Signup and view all the answers

    Cervicitis is a leading risk factor for ectopic pregnancy.

    <p>True</p> Signup and view all the answers

    What are the criteria for a cervical ectopic pregnancy?

    <p>Paalman (New), Rubin (Obsolete)</p> Signup and view all the answers

    The highest risk factor for ectopic pregnancy is __________.

    <p>previous history of ectopic/tubal surgeries</p> Signup and view all the answers

    Match the following ectopic pregnancy sites with their criteria:

    <p>Cervical = Paalman (New), Rubin (Obsolete) 1° abdominal = Studdiform Ovarian = Spiegelberg 2° abdominal = From fimbrial end</p> Signup and view all the answers

    What is the site of a cornual pregnancy?

    <p>Interstitium of fallopian tube or rudimentary horn of uterus</p> Signup and view all the answers

    Intrauterine pregnancy occurs in the lateral relation to the round ligament.

    <p>False</p> Signup and view all the answers

    Name one characteristic of a cervical ectopic pregnancy.

    <p>Internal os closed</p> Signup and view all the answers

    A second-degree _____ pregnancy is the most common type of abdominal ectopic pregnancy.

    <p>abdominal</p> Signup and view all the answers

    Match the ectopic pregnancy types with their criteria:

    <p>Cervical Ectopic = Sac attached to endocervix Ovarian Ectopic = Sac present in ovary Abdominal Ectopic = Pregnancy attached to peritoneum Cornual Ectopic = Located in interstitium of fallopian tube</p> Signup and view all the answers

    What is the preferred surgical management for a patient with unstable vitals due to ectopic pregnancy?

    <p>Laparotomy</p> Signup and view all the answers

    Culdocentesis is indicated for stable ectopic pregnancies.

    <p>False</p> Signup and view all the answers

    What is the indication for performing a culdocentesis?

    <p>Ruptured ectopic pregnancy</p> Signup and view all the answers

    In cases of ectopic pregnancy, a surgical procedure termed ________ is performed regardless of family completion.

    <p>unilateral salpingectomy</p> Signup and view all the answers

    Match the following surgical procedures with their descriptions:

    <p>Laparoscopy = Minimally invasive surgery for stable patients Laparotomy = Open surgery for unstable patients Oophorectomy = Removal of the ovary only in ovarian ectopic Salpingectomy = Removal of the fallopian tube in ectopic pregnancy</p> Signup and view all the answers

    Study Notes

    Management Algorithm

    • Successful medical therapy: hCG fall ≥15%
    • Surgical therapy: hCG fall <15%

    Other Investigations

    • Laparoscopy: Gold standard
    • Serum progesterone: ≥25ng/mL indicates a live intrauterine pregnancy

    Role of Progesterone in Ectopic Pregnancy

    • Corpus luteum secretes progesterone
    • Progesterone levels: higher than a non-pregnant state, but lower than a normal pregnancy
    • Decidua vera present: Not differentiated into decidua basalis/capsularis/parietalis

    Anatomy of Fallopian Tube

    • Parts (medial to lateral): Interstitium (Intramural) → Isthmus → Ampulla → Infundibulum
    • Narrowest part: Interstitium > Isthmus
    • Sphincters:
      • Anatomical: Interstitium
      • Physiological: Isthmus

    Duration of Ectopic Pregnancy

    • Longest Duration: Interstitium (due to myometrial support) – most dangerous site (↑ bleeding)
    • Shortest Duration: Isthmus

    Site of Ectopic Pregnancy

    • Fallopian tube: Most common
      • Most frequent part: Ampulla - site of fertilization, maximum number of plicae (mucosal folds)
    • Most frequent non-tubal: Ovary
    • Less Common: C-section scar > Cervical ectopic > Abdominal ectopic
    • Note: Abdominal ectopic → lasts for a long time (derives blood supply from adjacent organs).

    Timing of Pregnancy Termination

    • Isthmus: 6-8 weeks
    • Ampulla: 8-10 weeks
    • Interstitium: 12 weeks

    Ruptured Ectopic Pregnancy

    • Diagnosis: Positive urine pregnancy test
    • Symptoms suggestive of rupture:
      • Ectopic pregnancy triad + any one of the following:
        • Shoulder tip pain
        • Urge to defecate
        • Orthostatic hypotension

    On Examination

    • Possible: Shock
    • Per abdomen:
      • Abdominal distension
      • Rigidity
      • Guarding
      • Localizing signs
      • Rebound tenderness
      • Uterus: Enlarged but smaller than expected for the period of gestation

    Abdominal Pain

    • Most specific/consistent symptom
    • Site: Lower abdomen (Localized)
    • Nature: Sharp/dull, unilateral

    Pathophysiology of Pain

    • Ruptured ectopic: leads to hemoperitoneum
      • Presents with:
        • Mid/upper abdominal pain
        • Danforth sign: Shoulder tip pain
        • Urge to defecate: Blood in rectum (cul-de-sac irritation)
    • Unruptured ectopic: Due to stretching of the fallopian tube (transmitted via TII, TI2, LI)

    Unruptured Ectopic

    • Investigations: Amenorrhea + bleeding P/V + Pain abdomen → 1st step: UPT (+ve in 99% cases d/t hCG) → TVS: 10C

    Approach

    • Diagnostic: TVS
      • Presence of gestational sac & yolk sac in fallopian tube → Medical management
      • Tubal sign/Bagel sign: Fallopian tube → Surgical management
      • Ring of fire sign: ↑ vascularity around ectopic → Surgical management
      • Empty uterus → Surgical management
      • Complex adnexal mass: Most common - D/t areas of hemorrhage → Surgical management
    • Inconclusive: Proceed with ß hCG measurement.

    ß HCG

    • Critical Titre: Value at which gestational sac is visible in an intrauterine pregnancy
      • ≥2000 IU + No gestational sac → Unruptured ectopic
      • 1500 - 2000 IU: Repeat ß hCG after 48 hours
        • ↑ value of hCG ≥50% on 2 occasions → Unruptured ectopic
        • Unchanged or ↓ value of hCG → Normal IUP or Ectopic pregnancy
        • Repeat TVS for confirmation
      • <1500 IU: Repeat ß hCG after 48 hours
        • ↑ value of hCG ≥50% on 2 occasions → Unruptured ectopic
        • Unchanged or ↓ value of hCG → Normal IUP or Ectopic pregnancy
        • Repeat TVS for confirmation

    Outcome

    • Tubal abortion: Occurs in the fimbrial end of the tube. Most frequent site: Ampulla.
    • Tubal rupture: Due to continuous growth of ectopic. Most frequent site: Isthmus.

    Criteria for various sites

    • Cervical: Paalman (New), Rubin (Obsolete)
    • 1° abdominal (2° abdominal: From fimbrial end): Studdiform
    • Ovarian: Spiegelberg

    Risk Factors & Clinical Features of Ectopic Pregnancy

    RISK FACTORS

    • Most common cause: PID/Salpingitis
    • Highest risk: Previous h/o ectopic/tubal surgeries
    • Other risk factors: Cervicitis, multiple partners, smoking, risk factors for PID, previous h/o C-section, infertility & ART, contraceptives.
    • Note: Adhesion formation can prevent implantation in the uterus.

    Relative Risk

    • Failure of contraceptive → increased chance of ectopic pregnancy
    • Highest risk factors:
      • a. Tubal ligation > Progesterone IUCD (mirena, progestasert) > Copper IUCD.
      • b. POP > OCP (Progesterone : Smooth muscle relaxant Peristalsis).

    Angular vs Cornual Pregnancy

    • Cornual pregnancy: Interstitium of fallopian tube/ rudimentary horn of uterus. Relationship to round ligament: Lateral.
    • Angular pregnancy: Near angle/cornua of uterus.
    • Intrauterine pregnancy: Relationship to round ligament: Medial.

    Criteria for Non-Tubal Ectopic Pregnancies

    Cervical Ectopic (Paalman criteria)

    • Internal os: Closed
    • External os: Partially open
    • Sac: Attached to endocervix
    • Bleeding without uterine cramps

    Ovarian Ectopic (Spiegelberg criteria)

    • Sac: Present in ovary
    • Tubes: Normal
    • Gestational sac: Attached to uterus by ovarian ligament
    • HPE: Ovarian tissue in gestational sac

    Abdominal Ectopic (Studdiform criteria)

    • Uteroperitoneal fistula

    • Tubes & ovary: Normal

    • Pregnancy attached to peritoneum

    • Note: Second-degree abdominal ectopic pregnancy is the most frequent type.

    Management

    • Note: Cervical motion tenderness + PID-UPT -ve ⇒ Ectopic pregnancy
      • UPT +ve/↑BhCG ⇒ Surgical management
    • Stable vitals: Laparoscopy
    • Unstable vitals: Laparotomy

    Surgery

    • U/L salpingectomy: Irrespectively of family completion.
    • Oophorectomy: Only in ovarian ectopic.
    • C/1 in ruptured ectopic: Expectorant mx. or medical mx.
    • Surgery other than salpingectomy: Consider if the patient desires future pregnancies.

    Culdocentesis

    • Indication: Ruptured ectopic

    • Principle: Pouch of Douglas

    • Syringe introduced into cul-de-sac/pouch of Douglas via posterior fornix

    • Aspirate after a while:

      • Blood clots: Needle in blood vessel
      • Blood does not clot (Devoid of clotting factors) : Needle in POD
      • Hemoperitoneum: Of ruptured ectopic

    • Note: Culdocentesis results are not confirmatory for ruptured ectopic pregnancy, further examination and investigation is required.

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    Description

    Test your knowledge on the management of ectopic pregnancy, including the roles of hCG levels, progesterone, and surgical options. This quiz covers anatomical details of the fallopian tube and the duration and site of ectopic pregnancies.

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