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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 contraindic-


ated 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. Most common cause of ectopic pregnancy is: (AI 96)


a. IUCD
b. Previous tubal disease
c. Endometriosis
d. Mini pills

265. Ectopic pregnancy is seen maximum with: (JIPMER 98)


a. IUCD
b. OC pills
c. Barrier method
d. Tubal insertion

128
Ectopic Pregnancy 129
266. Commonest cause of ectopic gestation: (Kerala 96)
a. Previous salpingitis
b. Dysfunction of cilia
c. Uterine abnormalities
d. Delayed fertilization of ovum
e. Hydrosalphynx

267. Which one of the following drug is not used for medical managem-
ent of ectopic pregnancy? (AIIMS 2003)
a. Kcl
b. Methotrexate
c. Actinomycin D
d. Misoprostol

268. Medical treatment of ectopic pregnancy is: (AIIMS 96)


a. Methotrexate
b. Progesterone
c. Oestrogen
d. 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. Diagnostic criteria for primary abdominal pregnancy: (Orissa 99)


a. Spigelberg criteria
b. Rubin’s criteria
c. Studdiford criteria
d. Wrigly criteria

272. Rupture of ampullary ectopic pregnancy occurs during: (AP 99)


a. 8 weeks
b. 12 weeks
c. 16 weeks
d. 20 weeks
130 Obstetrics & Gynaecology
273. Ectopic pregnancy is more common in: (PGI 90)
a. Tuboplasty
b. Endometriosis
c. CuT users
d. All of the above

274. The commonest site of ectopic gestation: (TN 2006)


a. Ovary
b. Broad ligament
c. Fallopian tube
d. All of the above

275. Which is the normal site of fertilization?


a. Infundibulum
b. Isthmus
c. Ampulla
d. 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. Most common cause of ectopic pregnancy is: (AIIMS 96)


a. Progestasert
b. Cu-T
c. OC pills
d. 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 List II
A. Triphasic 1. Prevention of ovarian tumors
B. DMPA 2. Good for women having hypomenorrhoea
C. Biphasic pill 3. Amenorrhoea is common
D. Progestin 4. Beneficial effect on HDLcontaining IUD
5. Chance of ectopic pregnancy

Codes:
a. A B C D
4 3 1 5
b. A B C D
4 1 3 5
c. A B C D
5 4 2 1
d. A B C D
5 3 4 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 documen-
ted 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 intra-
uterine 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 compar-
ed 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 management-
1. 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 intramusc-
ularly.

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
  Cervical
Extrauterine Uterine  Angular
Cornual
  
Tubal Ovarian Abdominal
(Commonest 95%)

     
Ampulla Isthmus Infundibulum Interstitial Primary Secondary
(55%) (25%) (18%) (2%) (rare)

 
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 Coil Failure rate Lasts for (Years)
——————————————————————————————
First Cu7 (200) >2/100 3–5
CuT (200) >2/100
Second Multiload Cu 250 1–2 /100 3–5
NovaT 1–2 /100 1–2/100
Third Multiload Cu 375 0.5–1.1/100 5+
Cu 380 0.3–1/100
Hormone Progestasert 1
releasing LNG-IUCD 0.5/100 at 1 yr 5
(Levenorgestrel 0.7/100 at 3 yr
Impregnated) 1/100 at 5 yr
——————————————————————————————

284. Ans: c (Contact dermatitis)


Contact dermatitis is the most common problem associated with
the use of condom.

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