128 Obstetrics & Gynaecology

Ectopic Pregnancy
Questions
261. Which of the following regarding Ectopic pregnancy is /are true: (PGI 2004) a. Occurs in about 10% of pregnancies b. The risk is increased in those with a history of PID c. Usually presents between 2 and 4 months of gestation d. Patients usually have a negative pregnancy test e. If patient is in shock, early laparotomy is essential 262. In a case of ectopic pregnancy, medical treatment is contraindicated if: (KAR 2005) a. Sac size is 3.0 cm b. Serum HCG levels > 1500 miu / ml c. Significant hemoperitoneum is present d. Absent fetal activity 263. In which of the following conditions the medical treatment of Ectopic Pregnancy is contraindicated? (AIIMS 2004 may) a. Sac size is 3cm b. Blood in pelvis is 70 ml c. Presence of fetal heart activity d. Previous ectopic pregnancy 264. a. b. c. d. 265. a. b. c. d. Most common cause of ectopic pregnancy is: (AI 96) IUCD Previous tubal disease Endometriosis Mini pills Ectopic pregnancy is seen maximum with: (JIPMER 98) IUCD OC pills Barrier method Tubal insertion

128

Ectopic Pregnancy 129 266. a. b. c. d. e. Commonest cause of ectopic gestation: (Kerala 96) Previous salpingitis Dysfunction of cilia Uterine abnormalities Delayed fertilization of ovum Hydrosalphynx

267. Which one of the following drug is not used for medical management of ectopic pregnancy? (AIIMS 2003) a. Kcl b. Methotrexate c. Actinomycin D d. Misoprostol 268. a. b. c. d. Medical treatment of ectopic pregnancy is: (AIIMS 96) Methotrexate Progesterone Oestrogen Adriamycin

269. Medical treatment of ectopic pregnancy includes all of the following drugs except: (Kar 94) a. Prostaglandins b. Methotrexate c. RU 486 d. Dexamethasone 270. The following drug is not useful in treatment of ectopic pregnancy: (AI 2005) a. Methotrexate b. Misoprostol c. Actinomycin-D d. RU-486 271. a. b. c. d. 272. a. b. c. d. Diagnostic criteria for primary abdominal pregnancy: (Orissa 99) Spigelberg criteria Rubin’s criteria Studdiford criteria Wrigly criteria Rupture of ampullary ectopic pregnancy occurs during: (AP 99) 8 weeks 12 weeks 16 weeks 20 weeks

130 Obstetrics & Gynaecology 273. a. b. c. d. 274. a. b. c. d. 275. a. b. c. d. Ectopic pregnancy is more common in: (PGI 90) Tuboplasty Endometriosis CuT users All of the above The commonest site of ectopic gestation: (TN 2006) Ovary Broad ligament Fallopian tube All of the above Which is the normal site of fertilization? Infundibulum Isthmus Ampulla Cornu

276. In which part of fallopian tube does ectopic pregnancy occurs most frequently: (Kar 93) a. Ampulla b. Isthmus c. Fimbria d. Cornu 277. The hormone responsible for the decidual and Arias Stella reaction of the ectopic pregnancy: (Kerala 2001) a. HCG b. Progesterone c. Estrogen d. HPL 278. a. b. c. d. Most common cause of ectopic pregnancy is: (AIIMS 96) Progestasert Cu-T OC pills Minipill

279. Third generation oral contraceptive pills containing norgestrel and gestodene along with estrogens: (DNB 2006) a. Are more lipid friendly b. Decrease the risk of venous thromboembolism c. Increase the risk of break through bleeding d. Are not used for emergency contraception

Ectopic Pregnancy 131 280. Which one of the following hormonal contraceptives CANNOT be used during lactation? a. Mini-pill b. Norplant c. DMPA d. Combined oral contraceptives 281. Match List I (Type of Pill) with List II (Effect) and select the correct answer using the codes given below the Lists: List I A. Triphasic B. DMPA C. Biphasic pill D. Progestin List II 1. Prevention of ovarian tumors 2. Good for women having hypomenorrhoea 3. Amenorrhoea is common 4. Beneficial effect on HDLcontaining IUD 5. Chance of ectopic pregnancy

a. b. c. d.

Codes: A 4 A 4 A 5 A 5

B 3 B 1 B 4 B 3

C 1 C 3 C 2 C 4

D 5 D 5 D 1 D 2

282. A primipara with a cardiac lesion (MI) has come on the 40th day of delivery asking for contraception. The contraceptive of choice is a. Condom with spermicidal jelly b. Oral contraceptive pill c. Intrauterine contraceptive device d. Laparoscopic sterilization 283. Which one of the following intrauterine contraceptive devices has the lowest pregnancy rate? a. Lippes loop b. Cu-7 c. Cu T-200 d. Levonorgestrel IUD 284. Which one of the following is the most common problem associated with the use of condom? a. Increased monilial infection of vagina b. Premature ejaculation c. Contact dermatitis d. Retention of urine

132 Obstetrics & Gynaecology

Ectopic Pregnancy
Answers
261. Ans. b and e Ectopic pregnancy Occur in about 1% of pregnancies It usually presents at between 6 and 8 weeks gestation A sensitive beta-HCG test is usually positive Occurs in 1% of pregnancies Mortality is less than 1% Commonest site is in the tubal ampulla Usually presents at 6-8 weeks amenorrhoea Clinical presentation: o Clinically patient has lower abdominal pain and slight vaginal bleeding o Cardiovascular collapse and shoulder tip pain suggest large intraperitoneal bleed o Examination will often shown abdominal and adnexal tenderness Management: o Patient invariably has positive urinary pregnancy test o In cases of doubt sensitive serum beta-HCG is helpful o Ultrasound shows empty uterus and may identify ectopic o An intrauterine pregnancy on USG almost invariably excludes an ectopic o If no evidence of cardiovascular compromise laparoscopy is investigation of choice o If patient is shocked immediate laparotomy is essential o Fetus can then be removed by salpingotomy or salpingectomy 262. Ans. c (Significant hemoperitoneum is present) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) EXPECTANT MANAGEMENT of ECTOPIC PREGNANCY Pregnancy of unknown location • Serum HCG levels are below the discriminatory zone (level at which it is assumed that a viable intra-uterine pregnancy would be visualised on trans-vaginal scan: 1000 – 2000 iu/l) • If no pregnancy is detectable on scan, the pregnancy is of unknown location • Discriminatory zone dependent on quality of ultrasound equipment, experience of the sonographer, prior knowledge of the woman’s risks and symptoms and the presence of factors such as fibroids and multiple pregnancy 132

Ectopic Pregnancy 133 • Women with minimal / no symptoms can be managed expectantly with 48-72h follow-up and active management if symptomatic, HCG levels rise above discriminatory zone or levels plateau • Intervention may be required in 23-29% of cases • Monitor serum HCG until below 20iu/l • Provide clear written information on the importance of compliance with follow-up and should have easy access to the hospital Expectant management - Ectopic pregnancy Criteria • Asymptomatic and haemodynamically stable • HCG low and falling (<1000iu/l) • < 100ml blood in pouch of Douglas • gestation sac < 5cm with no FH on scan • Low and rapidly falling HCG levels indicate high likelihood of successful expectant management • Perform twice weekly serum HCG levels and weekly transvaginal scans to ensure levels falling rapidly and size of ectopic mass decreasing. Thereafter, weekly HCG and scans until HCG < 20iu/l • Provide clear written information on the importance of compliance with follow-up and should have easy access to the hospital • Rupture may still occur under these circumstances. 263. Ans: b (Blood in pelvis is 70 ml) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) MANAGEMENT OF TUBAL PREGNANCY Laparotomy Viz Laparoscopy In a haemodynamically stable woman, laparoscopy is preferable to laparotomy. Laparoscopy associated with: • Lower blood loss • Lower analgesic requirement • Shorter hospital stay • Quicker post-op recovery • Lower cost • No significant difference in subsequent intra-uterine pregnancy rates • A trend towards a lower repeat ectopic pregnancy rate • Higher rate of persistent trophoblastic tissue (12.2% v 1.7%) if salpingotomy performed • Lower risk of adhesion formation IF THE WOMAN IS HAEMODYNAMICALLY UNSTABLE • Management should be by the most expedient method and in most cases, this would be by laparotomy

134 Obstetrics & Gynaecology SALPINGECTOMY Vs SALPINGOTOMY • Both tubes present – there does not appear to be a difference in subsequent intra-uterine pregnancy rate (46 v 44%) • Recurrent ectopic pregnancy rate appears to be higher after salpingotomy although data are conflicting • Risk of persistent trophoblastic tissue higher after salpingotomy – monitor HCG levels; risk of tubal bleeding in the immediate post-op period. These risks should be discussed and documented if salpingotomy is being considered or is requested • In women with one tube only or contra-lateral tubal disease – tubal conservation associated with a 54% intra-uterine pregnancy rate but a 20.5% recurrent ectopic pregnancy rate – appropriate pre-op counselling required. This is however, cost effective when the requirement for IVF is considered. 264. Ans. b (Previous tubal disease) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) Risk factors for ectopic pregnancy include: 1. Previous PID 2. Infertility 3. Tubal surgery 4. Intrauterine contraceptive device 5. Previous ectopic 6. PID increases risk of ectopic seven fold 265. Ans. a (IUCD) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) Risk factors for ectopic pregnancy include: 1. Previous PID 2. Infertility 3. Tubal surgery 4. Intrauterine contraceptive device (maximum risk) 5. Previous ectopic 6. PID increases risk of ectopic seven fold 266. Ans. a (Previous salpingitis) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) Ectopic Pregnancy • Incidence in UK 11.1 per 1000 pregnancies • Account for ~10% of all direct maternal deaths • Caused 13 maternal deaths in 1997-99 • Mortality has decreased 4 –fold in the last 20 years • Diagnostic laparoscopy has a false positive rate of 5% and a false negative rate of 3-4% • There is some debate on the level of HCG at which a viable intrauterine gestation sac should be detectable on trans-vaginal ultrasound scan but most would accept a level of >1500miu/l

Ectopic Pregnancy 135 • A rise in serum HCG of <50% in 48h is almost always associated with a non-viable pregnancy, ectopic or otherwise RISK FACTORS • PID • IUCD • Sterilisation • Tubal surgery • Previous ectopic • Assisted reproduction • Mini-pill • All current contraceptive users, including IUCD are less likely to have an ectopic pregnancy than sexually active women not using contraception • IUCD users (except MIRENA) are 3 times more likely to have an ectopic pregnancy than users of other contraceptives • Use of depot medroxyprogesterone acetate is associated with a lower risk of ectopic pregnancy than the mini-pill but higher than the Combined OC Pills. 267. Ans. c (Actinomycin D) (Ref. Textbook of obstetrics D C Dutta 6th ed. 202) MEDICAL TREATMENT • This should be offered to suitable women and units should have treatment and follow-up protocols Criteria for medical treatment 1) Ectopic mass <3.5cm – the presence of fetal cardiac activity is a contra-indication to medical treatment 2) No fetal cardiac activity 3) Initial HCG <3000iu/l • Success rates of 85-94% following single dose treatment – less expensive, fewer side-effects, requires less intensive monitoring and does not require folinic acid supplementation when compared to multiple dose regimens • Increase in abdominal pain is reported by 59% of women following methotrexate administration • A transient increase in beta-HCG may occur in up to 86% of women between days 1 and 4 of treatment. Serum beta-HCG should be measured on days 4 and 7. A further dose of methotrexate should be considered if HCG levels fall by less than 15% between days 4 and 7. • If medical treatment is offered, women should be given clear written information about the possible need for further treatment and potential complications. Women should be able to return easily for assessment at any time during follow-up • 7% of women experience tubal rupture during follow-up

136 Obstetrics & Gynaecology • About 75% of women will experience abdominal pain following treatment • Women should be advised to avoid sexual intercourse during treatment, maintain ample fluid intake and use reliable contraception for 3 months after treatment because of the possible teratogenic effects of methotrexate • Ipsilateral tubal patency rates following treatment are ~80% • Among women trying to become pregnant, intra-uterine pregnancy rate = 54% and recurrent ectopic rates = 8-10% - comparable to those following laparoscopic salpingostomy • Intra-muscular methotrexate (50mg/square m) COMPLICATIONS: • Stomatitis, alopecia, hematosalpinx, neutropenia, pneumonitis, multiple ovarian cysts, failed therapy. 268. Ans. a (Methotrexate) (Ref. Textbook of obstetrics D C Dutta 6th ed. 202) Treatment of ectopic pregnancy Medical management includes use of: 1. KCL, 2. Anti-HCG abs, 3. Ru486 and 4. Methotrexate. Criteria for medical management1. Sac size < 3.5cm 2. Stable patient 3. No jaundice 4. HB > 10gm% Laparoscopic management is the preferred treatment option in all but the haemodynamically compromised or in those with a large ectopic pregnancy (e.g., >5). Conversation of the tube by linear salpingostomy using unipolar needlepoint diathermy is effective, and the tube is left to close spontaneously. Salpingectomy can be carried out using a pre-tied loop or with excision using coagulation diathermy or by laparotomy where, in addition, the pregnancy may be milked through the fimbrial end of the tube. Non-surgical conservative technique is salphingcentsis which involves injecting 50% dextrose or methotrexate in the sac laparoscopically. If the tube is conserved it is essential to ensure that the hCG is falling; if not there is likely to be residual trophoblast. The hCG should fall to 25% of the pre-treatment level within 4 days of surgery.

Ectopic Pregnancy 137 269. Ans. d (Dexamethasone) (Ref. Textbook of obstetrics D C Dutta 6th ed. 202) The drugs commonly used in management of ectopic pregnancy are: methotrexate, Kcl, PGs, hyperosmolar glucose, or Mifepristone (RU486). A single dose of methotrexate 50 mg/M2 is given intramuscularly. 270. Ans: c (Actinomycin-D) (Ref. Shaw’s textbook of Gynacology-13th Edn-275) Criteria for medical management of ectopic pregnancy: The gestational sac is not more than 3.5cm. Serum HCG level net > 10,000 mIU/ml. Fetal cardiac activity absent. Patient can be followed up. Drugs used in treatment are: Methotrexate ± leucovorum Prostaglandin F2 α (Misoprostol) RU 486 RCI Hyperosmolar glucose 271. Ans. c (Studdiford criteria) (Ref. Textbook of obstetrics D C Dutta 6th ed. 204) Criteria laid down by Studdiford to diagnose primary abdominal pregnancy are: 1. Both tubes and ovaries are normal without evidence of recent pregnancy. 2. Absence of uteroperitoneal fistula 3. Presence of pregnancy related exclusively to the peritoneal surface and young enough to eliminate the possibility of secondary implantation following primary radiation in the tube. 272. Ans. b (12 weeks) (Ref. Textbook of obstetrics D C Dutta 6th ed. 194) Tubal rupture is predominantly common in isthmic and interstitial implantation. Isthmic rupture usually occurs at 6-8weeks, the ampullary one at 8-12weeks and the interstitial one at about 4 months. 273. Ans. d (All of the above) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) Sites of Ectopic Pregnancy • 0.5% - ovarian • 0.1% intra-abdominal

138 Obstetrics & Gynaecology Tubal Pregnancy • 2% cornual • 55% ampulla • 17% fimbrial end • 25% isthmus 274. Ans. c (Fallopian tube) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191, flowchart) Sites of Ectopic Pregnancy • 0.5% - ovarian • 0.1% intra-abdominal Tubal Pregnancy • 2% cornual • 55% ampulla • 17% fimbrial end • 25% isthmus 275. Ans. c (Ampulla) Usually fertilization occurs in AMPULLA. 276. Ans. a (Ampulla) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191, flowchart)
Ectopic Pregnancy Extrauterine Uterine Cervical Angular Cornual Abdominal

Tubal (Commonest 95%)

Ovarian

Ampulla Isthmus (55%) (25%)

Infundibulum Interstitial (18%) (2%)

Primary (rare)

Secondary

Intraperitoneal

Extraperitoneal (Broad ligament) (Rare)

277. Ans. a, b (Ref. Textbook of obstetrics D C Dutta 6th ed. 195) Arias Stella reaction is characterized by a typical adenomatous change of endometrial glands. Intraluminal budding together with a typical cell changes (loss of polarity of cells, hyperchromatic nuclei, vacuolated cytoplasm and occasional mitosis) are collectively

Ectopic Pregnancy 139 referred as Arias Stella reaction. This is strikingly due to progesterone influence. 278. Ans. a (Progestasert) (Ref. Textbook of obstetrics D C Dutta 6th ed. 191) The etiology of ectopic pregnancy include: Pelvic inflammatory disease Iatrogenic a. Contraceptive failure IUCD Use of progestin only pills Sterilization operation b. Tubal surgery c. Intrapelvic adhesions Previous ectopic pregnancy Prior induced abortion Developmental defects of the tube Distortion of the tube (fibroid or broad ligament cyst) Trans-peritoneal migration of the ovum Tubal spasm Early resumption of trophoblastic activity Increased decidual reaction Tubal endometriosis 279. Ans: a (Are more lipid friendly) A new device levonova contains 60 mg of levonorgestrel and releases hormone in very low doses (20 mg/ day). Incidences of ectopic pregnancies with its use is 6 fold higher in women who do become pregnant as compared to failure amongst cu- T users. However they are more lipid friendly. 280. Ans: d (Combined oral contraceptives ) 281. Ans: a Biphasic pill Prevention of ovarian tumors Triphasic Beneficial effect on HDL DMPA Amenorrhoea is common Progestin containing IUD Chance of ectopic pregnancy 282. Ans: a (Condom with spermicidal jelly) Condom with spermicidal jelly is best contraceptive measure for a postpartum female with heart disease.

140 Obstetrics & Gynaecology 283. Ans: d (Levonorgestrel IUD) Contraceptive failure: Cu T 380A and Levonorgestrel have got lowest rate, whereas progestasert has got highest rate of ectopic pregnancy. ——————————————————————————————
Generation First Second Third Hormone releasing Coil Cu7 (200) CuT (200) Multiload Cu 250 NovaT Multiload Cu 375 Cu 380 Progestasert LNG-IUCD (Levenorgestrel Impregnated) Failure rate >2/100 >2/100 1–2 /100 1–2 /100 0.5–1.1/100 0.3–1/100 1 0.5/100 at 1 yr 0.7/100 at 3 yr 1/100 at 5 yr Lasts for (Years) 3–5 3–5 1–2/100 5+

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5

—————————————————————————————— 284. Ans: c (Contact dermatitis) Contact dermatitis is the most common problem associated with the use of condom.