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MRCOG PART 2 SBAs and EMQs

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ESSAY 195 - Bleeding in early pregnancy

Posted by Kishor S.
The most possible diagnosis in this woman is a ruptured ectopic pregnancy and prompt action should be started as it can cause maternal mortality. The immediate management will be resuscitation. Oxygen with facial mask will be given after checking the airway. Large bore IV line with Hartmann?s solution will be started. Drip will be completely open and if not going fast, it may require use of pressure bag. At the same time, blood sample will be taken for Hb, blood grouping and cross matching (at least four units) and immediate help will be sought from the staff, which may be doctor, nurse or midwife. A clinical assessment will be made that will include degree of pallor and presence of free fluid in abdomen. This will give approximate idea of concealed blood loss. If there is delay in cross matching, O Rh negative will be started followed by the cross-matched blood.
She requires emergency laparotomy and OT staff and anaesthetist will be informed. In the presence of an active bleeding following rupture ectopic pregnancy, it may not be possible to bring up BP and pulse to completely normal with these resuscitative measures. This fact will be discussed with the anaesthetist and unnecessary delay should be avoided.

If there is tubal rupture, which is most likely, salpingectomy will be done. But if she had already had previous salpingectomy for a prior ectopic, conservative surgery may be tried. This will depend on the site of rupture and her haemodynamic state as the procedure will take additional operating time. If the mid portion of the tube is involved and there is at least reasonable length (4 to 5 cm) of tube beyond the sac, then resection of affected portion and end-end anastomosis will be done. The specimen will be sent for histology.

Quantity of blood to be transfused will be approximately guided by the amount of haemoperitoneum and haemoglobin level. Fluid replacement will be carefully monitored during immediate postoperative period with urine output through indwelling urinary catheter. If the urine out is not satisfactory CVP line will be set up to guide fluid replacement. Antibiotic prophylaxis will be given. If she is Rh negative non immunized, Anti-D 250 IU will be given. Risk of VTE will be assessed and since she has lost an excessive amount of blood if there is any additional risk factor, heparin thromboprophylaxis will be given.

Lastly, as part of occupational health, everyone involved in the patient?s care should take local protocol of universal precaution while handling blood.

While she is recovering she will be provided with the detailed information of what has been done. Since the association of PID with tubal pregnancy is very high, a course of doxycycline will be given and she will be told that there is still risk of 20% recurrence in the remaining/left tube. If both the tubes are removed, IVF will be the answer to her desire to have any child.
Posted by Balakrishnan V.
Most probable diagnosis is ruptured ectopic pregnancy in view of her positive pregnancy test and empty uterus at 8 weeks of gestation. Initial management is to resuscitate her. Senior gynaecologist, anesthetist and haematologist should be called for help as its a gynaecology emergency. Theatre should be informed as she will need laparotomy to secure bleeding from ruptured ectopic.
It should be ensured that her airway is patent and she is breathing. Two large bore (16G or 14G) canulas should be insited in both arms and blood taken for group and screen six units of blood, full blood count, urea and electrolyte, coagulation profile. Intravenous colloids or crystalloids infusion should be started. Group specific uncrossmatched blood or O negative blood tranfusion can be given in the case of severe hypotension in collaboration with the haematologist.
After resuscitation she should be transferred to theatre for emergency laparotomy. There is no role of medical management of ectopic pregnancy in haemodynamically unstable patient. Senior and skilled person should be involved as she is haemodynamically unstable. If expertise is available laparoscopic management of large haemoperitoneum can be done.
General anaesthesia is preferred to regional anaesthesia as it avoids hypotension and saves time. Abdomen should be opened by pfennenstiel incision as it gives full view of pelvis and cosmeticaly better than midline incision. According to Royal College of Obstetricians and Gynaecologist guideline if other tube is healthy salpingectomy of ruptured tube should be done as it is associated with less rate of future ectopic pregnancy and persistant trophoblast.The peritoneal cavity should be cleared of all blood and lavaged with warm normal saline to minimise the chances of infection. A drain should be put in and abdomen closed.
She should be kept in high dependency unit for 24 to 48 hours for intensive monitoring of pulse, blood pressure and out put. The main postoperative risks are acute renal shutdown, thromboembolism and adult respiratory distress syndrome. So fluids should be titrated according to her output which should be maintained around 60 mls per hour. TED stockings and Low molecular weight heparin prophylaxis should be started per hospital protocol.
When she is stable a debriefing of the events should be given to her by the consultant. She should be offered psycological support if required. In view of her future wish of pregnancy she should be counselled that her chances of getting pregnant are not reduced by taking out one tube but her chances of future ectopic pregnancy are high as compared to general population. She should be given anri D injection 250 IU if she is non sensitised rhesus negative. She should be given proper contraception. Progesteron only pills are contraindicated as slow down tubal motility and may increase chances of ectopic pregnancy. In case of getting pregnant she should seek advice early to rule out ectopic pregnancy.
Posted by Kishor S.
The most possible diagnosis in this woman is a ruptured ectopic pregnancy and prompt action should be started as it can cause maternal mortality. The immediate management will be resuscitation. Oxygen with facial mask will be given after checking the airway. Large bore IV line with Hartmann?s solution will be started. Drip will be completely open and if not going fast, it may require use of pressure bag. At the same time, blood sample will be taken for Hb, blood grouping and cross matching (at least four units) and immediate help will be sought from the staff, which may be doctor, nurse or midwife. A clinical assessment will be made that will include degree of pallor and presence of free fluid in abdomen. This will give approximate idea of concealed blood loss. If there is delay in cross matching, O Rh negative will be started followed by the cross-matched blood.
She requires emergency laparotomy and OT staff and anaesthetist will be informed. In the presence of an active bleeding following rupture ectopic pregnancy, it may not be possible to bring up BP and pulse to completely normal with these resuscitative measures. This fact will be discussed with the anaesthetist and unnecessary delay should be avoided.

If there is tubal rupture, which is most likely, salpingectomy will be done. But if she had already had previous salpingectomy for a prior ectopic, conservative surgery may be tried. This will depend on the site of rupture and her haemodynamic state as the procedure will take additional operating time. If the mid portion of the tube is involved and there is at least reasonable length (4 to 5 cm) of tube beyond the sac, then resection of affected portion and end-end anastomosis will be done. The specimen will be sent for histology.

Quantity of blood to be transfused will be approximately guided by the amount of haemoperitoneum and haemoglobin level. Fluid replacement will be carefully monitored during immediate postoperative period with urine output through indwelling urinary catheter. If the urine out is not satisfactory CVP line will be set up to guide fluid replacement. Antibiotic prophylaxis will be given. If she is Rh negative non immunized, Anti-D 250 IU will be given. Risk of VTE will be assessed and since she has lost an excessive amount of blood if there is any additional risk factor, heparin thromboprophylaxis will be given.

Lastly, as part of occupational health, everyone involved in the patient?s care should take local protocol of universal precaution while handling blood.

While she is recovering she will be provided with the detailed information of what has been done. Since the association of PID with tubal pregnancy is very high, a course of doxycycline will be given and she will be told that there is still risk of 20% recurrence in the remaining/left tube. If both the tubes are removed, IVF will be the answer to her desire to have any child.
Posted by Ebeinheizer S.
I would make a clinical diagnosis of ruptured ectopic pregnancy based on her clinical presentation and ultrasound findings.Her positive urine pregnancy test at around 5 weeks amenorrhoea and still positive makes her around 8-9 weeks pregnant. Ultrasound should show a fetus or at least gestational sac by now but the findings were consistent with ruptured ectopic.

Delegating someone to trigger gynaecological emergency red alert to get senior help (gynaecologist), anaesthetist, SHO, nursing staff and porter would ensure quicker response and all the required help in the management. It would also free me to for immediate resuscitation of the patient. At the same time, the operating thetre, blood bank and laboratory should be alerted to ensure quick response for this patient.

Resuscitation would be in the approach of airway, breathing and circulation. Adequate oxygenation, maintenance of breathing and volume replacement is important to prevent serious morbidity and even mortality due to cerebral and peripheral tissue hypoxia. Head lowering, Guedel airway, oxygen supply and intubation/bagging if no spontaneous breathing is necessary. Two large bore (14G-16G) IV cannula should be sited and blood sent for cross match, FBC and coagulation screen. Volume replacement can be started immediately with 1 unit O-negative blood, colloids (maximum 1.5L to prevent pulmonary oedema) and crystalloids as she is in haemorrhagic shock.Insertion of CVP and FBC would dictate amount of fluid and blood that need to be given. Coagulation profile would dictate coagulopathy correction if needed.

Once the patient is haemodynamically stable, I would perform an emergency laparotomy because technically it is faster and easier. Consent is not necessary as it is life-saving and patient is unresponsive.If next of kin is around,I would give a brief explanation of what is happening to prevent misunderstanding.Depending on the intra-operative finding,I would perform salphingostomy(preserving the tube), salphingectomy of simply excision of ectopic (ovarian/cornual/abdominal ectopic). I would insert a drain upon closing to drain collected blood which is a potential source of irritation/pain, infection and adhesion.

Post-operative management would need adequate analgesia to relieve pain. IM anti-D if Rhesus negative to prevent sensitization. Thromboprophylaxis (hydration/TED stockings/LMWH) depending on other risk factors apart from her emergency operation is important to prevent thrombo-embolic events. Correcting anaemia, if any, with iron tablets or blood transfusion if severe/symptomatic would ensure speedy recovery.

Before discharge,I would counsel the patient (and partner) that the operation was performed as life saving measure. Intra-operative findings, procedure performed and any complications would be explained with diagrams. Risk of recurrence and future fertility would be addressed with written leaflets. This aleviates anxiety, reduces potential misunderstanding and litigation. She would be offered contraception, avoiding IUCD which has higher risk of ectopic pregnancy. COCP and other progestogen based preparations are option (except Cerazete and Mirena which has higher ectopic rates). If she wants to conceive again, I would advise for at least 1-2 menstrual cycles to pass to give her adequate time to recuperate.
Posted by Sreekala S.
The most probable diagnosis is a ruptured ectopic pregnancy which is a surgical emergency. Emergency buzzer should be used to alert the staff of this emergency. The on call SHO, Registrar ,Consultant ObstetricianGynacologist and the anaesthetist should be informed. Airway should be checked and kept patent. Breathing should be ensured.The patient should be put in the recovery position. Oxygen inhalation should be given at 15liters/min. Two large bore IV cannulae should be sited at the antecubital fossae and blood drawn for FBC, Coagulation profile, U&Es and crossmatch 6 untis. The blood bank and the porters should be informed of the emergency situation and the bloods properly labelled. IV fluids like hartmans or normal saline should be commenced as soon as possible at the fastest rate possible. Blood should be commenced when available. Group specific blood is always preferable to O negative blood. O negative blood may be given if there is going to be a delay in obtaining crossmatched group specific blood.
The Operation theatre staff should be alerted. An urgent laparotomy should be performed. If the fallopian tube is involved then salpingectomy is preferable to salpingotomy as salpingotomy increases the risk of an ectopic pregnancy in the future. BP and pulse should be carefully monitored. A CVP line may be required if she continues to be hemodynamically unstable. Urine output should be monitored. 250 IU of Anti D injection may be required if she is Rhesus negative. Thromboprophlaxis should be given in the form of LMWH. A FBC may be repeated on the following day to check her Hb. Further transfusions may be given after reviewing the FBC.
Post operatively, events should be explained and operative findings discussed with the patient. She should be counselled that there is a 20% risk of an ectopic pregnancy occurring in the remaining tube in the future and therefore it is advisable to get an early pregnancy scan after confirming a pregnancy.
Events should be documented well.
Posted by Tanzeem Sabina C.
From the history and given investigation, here the most possible diagnosis is ruptured ectopic pregnancy. It is an gynaecology emergency as 11 women had died in the last trennium (CEMACH 2000-02, report). So immediate resuscitation is the initial management. Senior gynaecologist, SHO, nursing staff, porter, anaeshesist and haematologist should be called for help and ODA staff should be informed for emergency laparotomy to prevent further blood loss. Laboratory and blood bank should also be informed to ensure quick responses.
Airway should be secured and oxygen with facial musk should be given if needed.
Two large bore I.V. canula ( 16G or 14G) should be inserted in both arms and blood should be sent for full blood count, grouping, crossmatching ( atleast 4-6 units of blood) and coagulation profile. I.V. colloids or crystalloids should be started immediately. Group specific crossmatched blood should be started as soon as available.
If there is any delay, then O Rh negative blood should be started followed by crossmatched blood.with the help of haematologist.
After resuscitation she should be sent to the operation theatre for laparotomy. She should be managed in dedicated early pregnancy assessment unit. Consent and a thorough but quick history about parity, wishes for future pregnancy, any history of infertility, ART (IVF, IUI in current pregnancy), pelvic inflammatory disease, tubal surgery (e.g. previous ectopic pregnancy,etc ) should be taken, if the patient is responsive or from other relative if present with the patient, which will help in surgical management of tubal pregnancy ( conservative or radical). There is no role of medical management in case of ruptured ectopic. Skilled and experienced surgeon should do the operation to facilitate safe surgery. Laparotomy is preferable to laporoscopy when the patient is haemodynamically unstable , as in our case. If experienced persons are available, laparoscopy may be done even in large haemoperitonium safely, but the surgical procedure which prevent further blood loss most quickly, should be used. The mode of treatment should be done according to the local protocol of the individual hospital. General anaestesia is preferable to regional anaesthesia as it is quicker and has better intra and post-operative outcome in haemodynamically unstable patient.
Royal College of Obstetricians and Gynaecologists recommend salpingectomy of the ruptured in the presence of contralateral healthy tube, as it is associated with less ectopic pregnancy rate and persistance trophoblastic disease with no change in future pregnancy rate in comparison with salpingotomy. But salpingotomy should be considered in the presence of contralateral tubal disease and desire for future fertility. In this case postoperative follow up trearment of persistant trophoblast may be needed and the woman must aware about further ectopic pregnancy. The peritoneal cavity should be washed with warm saline and a drain should be given before abdominal closer to prevent infection, pain and adhesion. She should be monitored carefully all vital signs( pulse, BP, temperature, urine output) in post operative period in high dependency unit for 24-48 hours. Postoperative analgesia should be given to reduce pain. Antibiotic prophylaxis should be given to reduce chances of infection.
Fluid intake output chart should be maintained and CVP line should be started as there is chance of pulmonary oedema, acute renal failure (urine output < 30ml/hour). Blood should be given according to blood loss and Hb level. If she is Rh negative and non immunized anti-RhD antibody 250 IU should be given. There is chance of VTE, early mobilisation, TED Stockings, LMWH. should be started for thromboprophylaxis according to local hospital protocol by assessing risk factor for thromboembolism.
When she is stable, she should be informed all the event that has been done. Psychological support should be given to her and her families. Plans for follow up should be clearly written in discharged letter from early pregnancy unit. She should be given written information about treatment option, follow up and the availability of local and national support services.If she wants to become pregnant again, it is better to wait for 2-3 months to recover. When she conceives, she should be informed to her GP to rule out ectopic pregnancy.
She should be given proper contraceptive advice. Progesterone only pills, IUCD slightly increases chance of ectopic pregnancy than COCP, but less than nonuser. If her salpingectomy was done and there was damaged or absent contra lateral tube in vitro fertilisation should be advised if she wants child.
Posted by Remi A.
This clinical features are highly suggestive of ruptured ectopic pregnancy.
The principles of management is immediate resuscitation,early multidisciplinary involvement and immediate laparotomy after resuscitation.

Patent airway should be ensured and she should be placed in recovery position.Oxygen should be administered by facemask.
Two large bore needle should be inserted for iv access,and blood taken for Full blood count,Group and xmatch 4-6 units of Blood,urea and electrolytes,and coagulation profile.
Rapid infusion of crystalloid or colloid.
Continous monitoring of Oxygen saturation,Blood pressure,pulse rate,respiratory rate,and a urinary catheter should be inserted to monitor output.
Senior multidisciplinary help-Gynaecologist,anaesthestist,Haematologist should be called.Operating theatre staff should be informed.
Rhesus negative should be administered if there is delay in crossmatch blood in liason with the haematologist.
Laparotomy should be performed as soon as she is stable.
At laparotomy,Ectopic site should be identified,and salpingectomy would be appropriate,as its associated with reduced risk of recurrence and persistent trophoblast.Salpingostomy may be an option if the contralateral tube is diseased.
Excised tube should be sent for histopathology to confirm pregnancy.
Postoperatively,close monitoring of Oxygen saturation,blood pressure and urinary output.
Indication for surgery and operation findings should be discussed as soon as possible.Recurrence risk[20%]should be discussed.
Appropriate thromboprophylaxis should be provided.
If salpingostomy was performed-serial bHCG until less than 20iu .
Anti-D should be given,if Rh-ve and unsentisised.
Letter to the G/P.
Follow- up appointment to discuss histology report and future reproductive plans
Posted by Vinayak B.
This is an acute emergency with possible diagnosis of ruptured tubal pregnancy leading to hypovolemic shock.

Immediate extra help should be asked for senior person extra staff nurse portar.. Meanwhile Emergency ABC(air breath Circulation ) should be established. Oxygen by face mask given .head low given to increase venous return. Two iv line with wide bore canula secured.and crystalloids started . To be replaced rapidaly as per the estimated blood loss and clinical condition of the patient . Which will help to maintain circulation and combat hypovolemia . blood should be collected for investigation cbc,coagulation screen and blood grouping and crossmatching .Minimum 3/ 4 bottles of blood should be arranged.As intraperitoneal hemorrhage is expected . Foleys catherisation done to measure output. Operation theatre staff , Senior obstetrician and anesthetist informed as definitive treatment is surgery only. laparotomy at earliest.
Her previous records are viewd if available . with attension towards obstetric history . any previous history of tubal surgery,. Condition of the patient discussed with relatives Immediate operation planned as life saving .. . Surgery done under general anesthesia . in view of hemodynamicaly unstable patient with possible tubal rupture laparotomy is prefered over laparoscopic surgery and paramedian incision prefered over transverse which gives quick access to ruptured tube and hemostasis achieved . Site of tubal rupture identified and partial or complete salphingectomy done . no place for conservative surgery or segmental resection.as tubal rupture has already occurred . . other tube and both ovaries inspected and any abnormality noted. which will help to counsel the patient for future reproductive outcome. Blood loss assessed and replaced if hypotension and olig uria persists even after crystalloids or fresh frozen plasma replacement. blood transfusion given if required if patient condition detoriates even o negative blood can be given to restore hypovolemia and tissue perfusion. full hemostasis achieved abdomen closed after sponge and instrument count .
Prophylactic antibiotic given . Rh prophylaxis Anti D immunoglobulin250iu im given to avoid future rh isoiimunisation . thromboprophylaxis risk severity assessed as excessive blood lossis a risk factor for thrombosis hence deterrent stockings or heparin inistered as per risk analysis .

Detail documentation of notes kept..post operatively patient should be managed in high dependency unit

leaflets with detail discharge notes with explaination of operation details handed to patient to clear her doubts . She can use Coc,iucd as a contraception except pop and mirena as per who eligibility criteria,Hematinics are given to the patient to improve her hemoglobin and iron storage

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Follow up visits arranged for recounselling to clear her doubts and future pregnancy outcome If other tube normal her chances intruerine pregnancy 60%of ectopic 18 20 % .. . Patient should be given information of early pregnancy assessment unit and Bhcg assessment and early tranvaginal scan in next pregnancy to confirm intrauterine pregnancy.to confirm site of pregnancy at earliest and avoid such emergency.

Posted by adnan S.
The most probable diagnosis here is rupture tubal pregnancy until proved otherwise and carries a risk of maternal mortality and morbidity from acute haemorrhage unless prompt assessment and treatment is undertaken. Airway,breathing and haemodynamic stability should be assessed .Help should be seeked from senior obstetrician and anesthetist.Fascial oxygen is given,2 wide bore canulas are inserted and blood is taken for FBC ,cross matching 4-6 units ,U&E,LFT .Resuscitation is started with crystalloid or Onegative blood depending on degree of compromise.Vitals such as pulse ,blood pressure and oxygen saturation should be monitored every 10-15 minutes initially at the same time transvaginal ultrasoundscan can rapidly confirm the presence of haemoperitoneam if there is any diagnostic uncertainity but expedient resuscitation and laprotomy should be undertaken.In the presence of contralateral healthy tube salpingectomy is done as there is no clear evidence that salpingostomy should be used in preference to salpingectomy.salpingectomy appears to have same subsequent intrauterine pregnancy rate as salpigostomy,although salpingostomy has a higher rate of persistant trophoblast.

Post operatively ,the woman should be offerd Anti-D if she is Rhesus negative and non sensitized .she should be about contraception and the risk of further ectopic pregnancy and given advice about early pregnancy assessment
Posted by SWATI M.
The diagnosis in her case is ruptured ectopic pregnancy. Immediate treatment should be undertaken as it can be fatal and also associated with maternal morbidity .
Resuscitation should be started. Oxygen should be given by facial mask if she is breathing or by Ambu?s bag and mask. Call for help, nurses / anaesthetic registrar. Start with two wide bore IV lines with crystalloids.Collect blood for FBC ,blood group and cross match 4 units as may need blood transfusion .Inform blood bank about the urgency and arrange for emergency exploratory laparotomy by informing operating theatre and anaesthetist.Self retaining urinary catheter should be inserted.
Since the woman is unresponsive and needs urgent laparotomy to save her life,next of kin person will be explained if accompanying her and documented properly as it has medico ?legal implications.
Laparotomy should be undertaken under general anaesthesia ,as she is haemodynamically unstable.Salpingectomy should be performed for ruptured tubal pregnancy as there will be active bleeding from the tube.Inspect opposite fallopian tube ,so that she can be counseled upon future fertility and findings can be documented for future reference. Remove blood / blood clots from the peritoneal cavity to minimize development of paralytic ileus ,post-op infection and adhesions later on.
Prophylactic antibiotics should be given to minimize post-op infections.Blood transfusion should be given depending upon amount of blood loss at haemoperitoneum.
Proper documentation after the procedure is important for medicolegal purposes.
Post-op vitals should be monitored in recovery with one to one care every 15 minutes till fully conscious and haemodynamically stable .Continue IV fluids and monitor urine output every 1 hour.Once haemodynamically stable ,she can be transferred to gynae ward.Adequate analgesia should be given by IM opiates ? pethidine.Counsel her about events happened ,diagnosis and procedure performed.when she is fully conscious .
Anti-D injection 250 units should be given IM if she is Rh negative and non-senstised.Appropriate thrombo-prophylaxis should be given according to the unit protocol.
Oral fluids should be started once fully conscious .Ambulate her as soon as possible to minimizes risk of thrombo-embolism and infections.Remove urinary catheter when ambulatory.
At discharge,provide advice about future contraception and discuss increased risk (15-20%) of recurrence of ectopic pregnancy and to contact early once she misses her periods to confirm intra-uterine pregnancy.
Oral iron should be prescribed if anemic .Give letter to GP.

Posted by Aroosha B.
The most probable diagnosis in this patient is disturbed ectopic pregnancy. management should start with basic resuscitation principles i.e. maintaining airway,breathing and circulation. Two wide bore cannulae should be maintained with fast administration of I/V fluids which can be hartmann?s solution followed by plasma substitutes if necessary. At the same time blood should be taken for grouping and crossmatching of atleast four units of blood. Help for additional staff i.e.doctors and nurses should be asked for and monitoring of her vital signs should be continued. In the mean time anaesthetist, senior obstetrician and operating theatre should be informed for an urgent laparotomy.
According to Royal college guidelines in a haemodynamically unstable patient, management of tubal pregnancy should be by the most expedient method which in most cases will be laparotomy, although experienced surgeons may manage laparoscopically. Laparotomy can be done by a pfannensteil incision which is usually sufficient unless there is h/o laparotomy before by a midline incision in which case opening via the previous incision would be preferred. In the presence of a healthy contralateral tube there is no clear evidence that conservative surgery(salpingotomy) should be used in preference to radical surgery (salpingectomy). Salpingectomy is associated with increased risk of recurrent ectopic rate as well as of persistent trophoblast and need for follow up with beta HCG till below twenty IU but salpingostomy can be attemted if there is only one tube or in the presence of disease in the contralateral tube and there is desire for future fertility. Partial salpingectomy with end to end anastamosis can be done if residual tube is expected to be atleast 4-5cm. After securing haemostasis , blood is cleared from the abdominal cavity with warm saline to avoid infection , adhesions and post operative pain . Blood transfusion according to the blood loss and vital signs. Foley?s catheter is inserted to access urinary output post operatively.
I/V antibiotics are given post operatively as well as anti-D if patient is RH negative (250 IU I/M) within 72 hours of operation. Thromboprophylaxis is given according to her risk status which is usually low dose injection heparin for five days post operatively.
She can be kept in high dependency units preferably for first 24 hours. Post operative counseling involves explanation of her condition and operation contraceptive advice is given. COCP is preferred as IUCD and progesterone only pills have an increased risk of ectopic. Contraceptives can be used for 2-3 months to ensure recovery. Recurrence risk of about 20% is their if other tube is present. If both tubes have been removed contacts of IVF centers are given . Postoperative haemoglobin level should be accessed before discharge and haematinics advised accordingly. Followup is arranged after two weeks to access her recovery and further advise if needed. In future pregnancy early antenatal visit to exclude an extrauterine pregnancy is recommended.
(SORRY FOR LATE REPLY)