Makindo Medical Notes

⚠️ An ectopic pregnancy must be suspected in any woman with a positive pregnancy test, amenorrhoea, abdominal/pelvic pain, or PV bleeding. A delayed or missed diagnosis can be fatal.

📖 About

• 🚺 Ectopic pregnancy is the leading cause of maternal death in the first trimester.
• 💡 Classic triad: positive β-HCG, amenorrhoea, and empty uterus on ultrasound.
• 🧪 In a normal pregnancy, serum β-HCG doubles approximately every 48 hours. A plateau or slow rise is suspicious.
• ⚠️ Digital vaginal examination should be deferred until resuscitation is available, as it can precipitate rupture.

🧬 Aetiology

• Occurs when the embryo implants outside the uterus.
• 📍 90% occur in the fallopian tube (most often ampullary region).
• Incidence: ~1 in 200 pregnancies; risk rises with maternal age.

🔬 Physiology

• Fertilisation normally occurs in the fallopian tube → zygote travels to uterine cavity.
• 🩹 Scarring, infection, or surgery can disrupt this process → ectopic implantation.

⚡ Risk Factors

• Previous ectopic pregnancy
• PID, endometriosis, IUCD use
• Previous abdominal or pelvic surgery
• Reversal of sterilisation or IVF
• Ovarian/uterine tumours or cysts
• Smoking 🚬

🩺 Clinical Features (Pre-Rupture)

• Amenorrhoea (5–8 weeks post-LMP)
• Unilateral lower abdominal pain (sharp, stabbing)
• PV bleeding with “prune juice” appearance
• Pregnancy symptoms: breast tenderness, nausea
• Vasovagal episodes, collapse, or shock if ruptured
• Shoulder-tip pain (from diaphragmatic irritation)
• Peritonitis if rupture occurs → 🚨 emergency

🧪 Investigations

• Serum β-HCG: Serial levels (abnormal rise suggests ectopic).
• Transvaginal ultrasound: Empty uterus, adnexal mass, free fluid.
• Rhesus status: Anti-D may be required in Rh-negative women.
• Laparoscopy: Definitive diagnosis if uncertainty remains.

🔍 Differential Diagnosis

• Acute appendicitis
• Acute PID
• Threatened or incomplete miscarriage

💊 Management

• Medical (stable, early cases):
  • 📉 β-HCG < 1500 IU/L, sac < 4 cm, no rupture → Methotrexate ± Misoprostol.
  • Monitor β-HCG until resolution. Side effects: nausea, mucositis, fatigue.
• Surgical:
  • 🚑 Emergency laparotomy + salpingectomy if unstable/ruptured.
  • 💉 Laparoscopic salpingotomy or salpingectomy in stable patients.
• Conservative:
  • For small (<2 cm), asymptomatic masses with β-HCG < 1000 IU/L.
  • Close follow-up: β-HCG should fall ≥15% per visit.
• Other:
  • Rhesus-negative → give Anti-D prophylaxis (250 IU).
  • Ongoing EPAU follow-up until β-HCG negative.

📚 References

• Royal College of Obstetricians and Gynaecologists Guideline