Etiology/
Definitions
Definitions
Two STI’s that can cause salpingitis
Gonorrhea and Chlamydia
These cells implant in the mucosa of the fallopian tube
Trophoblasts
In acutely ruptured ectopic pregnancy this sign is seen due to irritation of the phrenic nerve by blood and clotting in the abdominal cavity
Shoulder pain
This hormone is not detected in maternal circulation until after implantation.
hCG
What is the risk of getting a salpingostomy over a salpingectomy?
Risk of residual trophoblastic tissue remaining
An embryo with _______ seen within the uterine cavity is referred to as a viable IUP.
Cardiac activity
Higher levels of this hormone are induced by ovarian hyperstimulation during the use of ARTs that can also slow tubal motility. What else can a mimic of this hormone be found in that has the same effect?
Progesterone; Progestin in birth control
Invasion of the ectopic pregnancy into the underlying blood vessels can cause spotting from local bleeding into which cavity? What other cavity can it bleed into?
Endometrial cavity; Peritoneal cavity (hemoperitoneum)
What surgical procedure is usually required in an acutely ruptured ectopic with extensive tubal damage?
Salpingectomy
What is the doubling time for hCG in normal pregnancies?
48 Hours
What is the MOA of Methotrexate? What three labs do you need before giving Methotrexate?
Folic acid antagonist that inhibits DNA synthesis and cell replication; normal serum creatinine level, normal liver and blood count studies
In vitro fertilization and other efforts to enhance fertility with the use of ovulation-inducing drugs have resulted in a higher incidence of what?
heterotopic pregnancy
Greatest risk factor for ectopic pregnancy
Previous ectopic pregnancy
Blood collection between what two layers of the fallopian tube causes a clot which can lead to what clinical sign?
Serosal and mucosal layers; cervical motion tenderness
A patient has hemodynamic instability, cervical motion tenderness, and sudden onset of severe pelvic pain with a positive pregnancy. What is the best next step?
Surgical emergency
What is the range of hCG values in which an US image can first detect signs of IUP called? What is the most common set range? If you dont see an IUP by the upper limit of this range what can this mean?
Discriminatory zone; 1500-2000 mIU/mL; suspect ectopic or multiple gestations
What is the dose for single dose methotrexate treatment? How long is the fixed multidose regimen and when would you use this for a patient?
50 mg/m2; 8 day regimen MTX given IM every other day with folic acid rescue on the alternate days, reserved for patients with very high hCG levels or embryonic cardiac motion
What is the disposition from ED after initial B-hCG in a stable suspected ectopic pregnancy patient?
follow up in 2 days for repeat B-hCG levels
T/F: Pregnancy in a patient with prior tubal surgery for sterilization is assumed to be an ectopic pregnancy until proven otherwise.
True
Extensive bleeding between the layers of the fallopian tube can cause what type of necrosis? What can this lead to?
Pressure necrosis; can lead to acute rupture and hemoperitoneum
You have ruled out other pain producing problems in a patient with a +pregnancy test, notable pelvic pain, and vaginal spotting/bleeding. Can you rule out ectopic pregnancy? What physical exam findings could you expect to see in this patient that would make you think of a probable ectopic?
No; tenderness of abdomen, adnexal or cervical motion tenderness
On transvaginal US what can be visible by weeks 4.5-5? What are you looking for in the gestational sac on the transvaginal US to confirm an IUP?
Gestational sac visible; yolk sac or fetal pole
What should a patient avoid while taking MTX? What are the return precautions?
Avoid folate supplements, NSAIDS and alcohol, pelvic rest, sunlight exposure and strenuous physical activity; Sudden severe abdominal pain, shoulder pain, dizziness, weakness, syncope, vaginal bleeding
On US, free fluid in cul-de-sac; occasionally double-ring sign in adnexa can be ectopic pregnancy but most of the time it's a ____ _____ ___.
corpus luteal cyst
Name the 4 different parts of the fallopian tube site where ectopic pregnancies can be implanted from most common to least common.
Ampullary > isthmic > infundibular/fimbrial > interstitial cornual
What gets compromised in an ectopic pregnancy which leads to resorbed pregnancy or aborted pregnancy into peritoneal cavity? What symptoms do you see?
Local blood supply; asymptomatic
A patient with missed meses, lower abdominal pain, and vaginal bleeding and possible pregnancy test comes to the ED. US showed a thin triple layered endometrial stripe, and a small amount of fluid in cud-de-sac. What is the diagnosis at this time?
Pregnancy of unknown location
What two types of pregnancies are better visualized via MRI?
Cesarean scar pregnancies and cornual pregnancies
Both ACOG and ACEP recommend ___ micrograms of RhoGAM for Rh- women with ectopics diagnosed prior to ___ weeks' gestation due to the small volume of red cells in the fetoplacental circulation, although administration of a full dose of ___ micrograms is acceptable as well.
50; 12; 300
If you had to do a culdocentesis and you get the following fluid, what does each one mean?
1. Non clotting blood – ?
2. Clear fluid – ?
3. Purulent material – ?
1. Non clotting blood – hemoperitoneum
2. Clear fluid – ruptured ovarian cyst
3. Purulent material – acute infection