CASE PRESENTATION ECTOPIC PREGNANCY 32 year old woman PC: RIF pain and PV bleeding History of Presenting Complaint Admitted to GAU through A&E 5+5/40 weeks pregnant by dates Abdominal Pain Started Initially 10/10 3 days previously RIF pain, now generalised lower abdo severity at worst PV bleeding Dark red/brown spotting Para 0 History of chlamydia aged 15 Gynae History Fertility investiagtions age 19 (not laparoscopy) – was told she was unlikely to have children Has been trying to conceive for last 12 years Up to date with smears Past medical history – tonsillectomy History Continued No regular medication No relevant family history Smoker – 10 a day, social drinker On Examination HR 81 BP 125/84 Temp 36.5 degrees Abdo – mild RIF tenderness Speculum not done as due to have scan Hb 128 Progesterone 5.6 BhCG 453 U&E Normal Initial Investiagtions Emergency Scan (By Sami) 14x13x14mm peripherally thick walled hyperechoic lesion with central anechoic component demonstrating peripheral increased colour doppler flow located in the right adnexa surrpunded by heterogenous material? Retracted blood clot Adjacent to the left ovary is a unilocular cyst (34x32x24mm) containing low level echos – possible paraovarian cyst Suspected Diagnosis right sided leaking ectopic Booked for CEPOD in the afternoon What happened next… At 2200 that evening, told that unlikely to be on CEPOD before midnight as very busy Patient allowed to eat and drink Patient remains hymodynamically stable with minimal abdo pain The next day… Repeat bloods 48 hours later bHCG 557 = 23% rise Hb 125 So taken to CEPOD Adhesions (particularly POD and left pelvic side walls) Initial Findings at Laparoscopy Blood in the POD Damaged left tube with small paraovarian cyst adherent to left tube and bowel Right tube slightly swollen with small blood clot at fimbrial end Initial Findings at Laparoscopy Laparosocpy Left sided adhesions divided and cyst drained Salpingostomy to right tube Minimal diathermy to tube for haemostasis Follow up Uneventful recovery BhCG 1 week later = 31.2 Histology: A few chorionic villi associated with blood clot and with focal implantation site reaction onto tubal wall. No gestational trophoblastic disease Management of Ectopic Pregnancy Expectant Management Initial BhCG of 1500 or under hCG must drop to <50% of original value by 7 days hCG followed weekly until less than 15IU USS is repeated weekly If static or rising then may need medical or surgical management Successful in 70% of suitable women Medical Management Suitable for Unruptured No ectopic pregnancy fetal heart beat Adnexal hCG mass < 35mm <5000 IU Medical Management Need FBC, LFT and U&Es on day 1 and day 7 Methotrexate dose = 50mg/m2 bHCG day 1,4 and 7 If BhCG is not <15% at 7 days then needs repeat USS Need to measure BhCG once a week until less than 15 IU Surgical Management Should be performed laparoscopially wherever possible Offer salpingectomy unless other risk factors Consider salpingostomy if contralateral tube damage (1 in 5 may need further treatment) For salpingostomy – needs weekly BhCG until <5 IU For salpingectomy needs pregnancy test at 3 weeks post op Learning Outcomes Always discuss and councel for salpingostomy in case the contralateral tube is damaged Important to fully explore the pelvis before proceeding
