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MRCOG PART 2 SBAs and EMQs

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Essay 251 - Ectopic pregnancy

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		Posted by Anna A. Sat Jan 5, 2008 06:55 pm
a)This patient has high risk factor to develop ectopic pregnancy, thus the aim of investigation is to rule out the presence of ectopic pregnancy. A urine pregnancy test is a simple test to asses whether we are dealing with early pregnancy complication like ectopic pregnancy or miscarriages. Haemoglobin level should be sent to assess presence of anaemia, therefore enable early blood transfusion if surgery is needed. Blood group, Rhesus status and presence of maternal antibody should be obtained as anti D administration is needed if she needs surgical intervention. Transvaginal scan is important tools to see presence of intrauterine gestation sac or empty uterus. Size of adnexal mass if any and presence of fetal heart beat should be noted, the amount of free fluid should be measured as well. Β HCG level is required to assist the most appropriate option of management for ectopic pregnancy (conservative, medical or surgical management). b)This is a form of conservative management and it is only justified in a patient who is asymptomatic and haemodynamically stable. Other prerequisite criteria of conservative management of ectopic pregnancy include B HCG level of less than 1000 iu/ml; the size of adnexal mass should be less than 5cm with no fetal activity and minimal free fluid in pouch of Douglas (less than 100ml). The hospital which offers conservative management should have clear follow up protocol and easy access if complications arise. She should be given clear written information and the compliance of follow up should be stress on. B HCG level should be obtained twice perweek and weekly transvaginal scan (TVS) should be arranged. Once there is an evidence of reduction in the size of adnexal mass and decreasing trend of B HCG she can be seen weekly for TVS and B HCG measurement. If the patient develop symptom or the level of B HCG is increasing trend or level start to plateau, the conservative management should be abandoned. The follow-up should be continued until level of B HCG of less than 20iu/ml. She should be informed that medical management is viable option for her (ultrasound evidence of ectopic pregnancy) and it has better success rate than conservative management. c)The advantages of laparoscopic management over laparotomy include shorter hospital stay and faster recovery which lead to less cost burden to the patient. Laparoscopic is associated with less risk of intra-operative bleeding thus can reduce risk of blood transfusion. The requirement of analgesia is less in laparoscopic procedure. She should be informed that the chances of intrauterine pregnancy is comparable with laparotomy but there a small trend of less risk of recurrent ectopic pregnancy in laparoscopic procedure. Laparoscopic procedure is also associated with less risk of adhesions d)Laparoscopic surgery requires adequate equipment and presence of well trained staff. The surgeon must be competence in performing laparoscopic surgery and familiar with laparoscopic instrument. The risk of persistent trophoblastic disease is higher and the successful to eliminate the tubal pregnancy is less in laparoscopic salpingotomy as compared to laparotomy salpingotomy. This method may not be appropriate for haemodynamically unstable patient.
		Posted by Azza S. Sat Jan 5, 2008 08:53 pm
This patient has a high risk of ectopic pregnancy. Ectopic pregnancy is potentially a fatal disease. Serum estimation of HCG as well as a transvaginal ultrasound [TV-USS].If HCG Is found to be less than 1500iu/l and no pregnancy is found on TV-USS, so the HCG should be repeated after 48hours. If HCG is doubling , so this pregnancy is likely to be intra-uterine & follow-up TV-USS should be offered. If the HCG is found to be raising by less than 50% or platu so this pregnancy is likely to be ectopic. If HCG is found to be falling so this pregnancy is failing regardless of it site. There a place for expectant management in ectopic pregnancy. If the patient understand and agreed & with easy access to hospital and compliance for follow-up. The HCG level should be less than 1000iu/l & no ectopic pregnancy seen on TV-USS A written information leaflet should be given with follow- up with HCG twice weekly and TV-USS weekly. Then if start to fall down follow-up should be with weekly HCG till it is less than 20iu/l. If HCG is raising then active management is needed. There is success rate of 80% & 20% risk of rupture of the tube. Laparoscopic compared with laparotomy for the management of ectopic pregnancy, is associated with minimal blood loss, minimal need for analgesia, minimal hospital stay & less cost. There is no significant difference in the rate of subsequent intra-uterine pregnancy, and less repeat ectopic pregnancy. There is also less adhesion formation. Laparoscopic management require expensive equipment and trained operator. It take longer time for most of operators. There is increased risk of persistent trophoblastic tissues which require follow-up. There is risk of visceral injury and need for laparotomy in case of injury or if failed entry.
		Posted by Sahathevan S. Sat Jan 5, 2008 10:42 pm
(a) Justify your initial investigations [5 marks]. She is high risk for ectopic pregnancy,however the differential diagnosis are ectopic pregnancy, Threatened Miscarriage, Delayed miscarriage, incomplete miscarriage, Anembryonic pregnancy or Pregnancy of unknown location. Ectopic pregnancy is potentially serious condition and delay in diagnosis carries risk of rupture which is a life threatening complication. Prompt diagnosis is important to prevent maternal morbidity or mortality. She has history of Pelvic inflammatory disease (PID) and subfertilty which are the risk factors for ectopic pregnancy. Also any history of treatment with ovulating induction agents or tubal surgeries or IVF in relation to her subfertilty potentially increase the risk. As a baseline investigation FBC and Group and save serum to be performed to investigate her Hb level and Blood group. The two most important tools are determination serum Beta HCG and Transvaginal ultrasound (TVS). TVS usually reveals an intrauterine pregnancy when serum HCG level exceeds 1500 mIU/ ml. Finding of an intrauterine gestation almost always exclude the presence of an ectopic pregnancy unless IVF has been performed (incidence of hetreotropic pregnancy 2-11% in IVF) A delayed Miscarriage will be diagnosed by TVS If the fetal pole > 6mm and no fetal heart beat identified, also an anembryonic pregnancy if Gestational sac > 20mm with no fetal pole. TVS Findings of empty uterus, free fluid in Pouch of Douglas (POD), adnexal mass (may be with fetal heart (FHB) with Beta HCG level of > 1000 IU, highly suggestive of ectopic pregnancy. Serum Progesterone is limited value as an initial investigation as it is higher in viable IUP than non viable pregnancies, including ectopic pregnancies and failing IUP. However it may be useful as a supportive investigation. If she has Serum HCG level below the discriminatory zone (1000-15000 IU) and no pregnancy identified on TVS, the diagnosis can be made as pregnancy is of unknown location. (b) A right tubal ectopic pregnancy is identified. She is discharged home with a follow-up appointment. Justify this management [5 marks]. Decision was made to manage for Right tubal ectopic pregnancy conservatively. The reason for the Choice of the expectant management would have been the history of previous left salphingectomy for ectopic or tubal disease due to PID. Other possibilities any contraindication for Methotrexate treatment (Medical) or patient choice. However she should have had fulfilled the criteria for safe conservative management, she should have been asymptomatic with low HCG level (<1000 IU) and which is falling and blood in POD <100ml and No FHB in ectopic mass identified on TVS. She should be followed up with twice weekly serum HCG level and weekly USS to ensure the levels are falling rapidly and ectopic mass is decreasing in size. She should be provided with written information and hospital contact details. Afterwards weekly HCG and scan until HCG < 20 IU /l She should be warned that rupture may still occur any stage during follow up which may need lapraotomy or Laparoscopic salphingectomy (c) She subsequently undergoes laparoscopic salpingectomy. What are the advantages of laparoscopic treatment compared to laparotomy [5 marks]? In a haemodynamically stable patient Laparoscopy preferable to laparotomy because it is associated with lower blood loss, lower analgesic requirement, shorter hospital stay, quick post op recovery, lower risk of adhesion formation, comparable intrauterine pregnancy rates, and lower cost possibly a lower repeat ectopic pregnancy rate. (d) What are the disadvantages of laparoscopy compared to laparotomy [5 marks]? Higher rate of persistent trophoblastic tissue after laparoscopic salphingostomy requires training and equipment and Contraindicated in shocked patient are the disadvantages. Also this patient may have extensive pelvic adhesions due to previous PID which could make the laparoscopy more difficult and increase risk of failure of procedure or visceral injuries. Laparotomy remains the mainstay of management of the ruptured ectopic pregnancy if the patient is haemodynamically unstable, Cardiovascular or respiratory problems and extensive pelvic adhesions.
		Posted by SAIMA A. Sat Jan 5, 2008 11:18 pm
Her history and symptoms suggests increase risk of ectopic pregnancy that need to be excluded . In early pregnancy clinic transvaginal ultrasound(TVS) should be done to detect presence or absence of intra uterine gestational sac(IUGS) ,presence of adnexal mass with or without free fluid in pouch of Douglas.If no IUGS seen on TVS,this is pregnancy of unknown location and further investigations are warranted in form of serum BHCG .serum B HCG level below discriminatory zone (less than 2000 iu/l) need to repeat after 48 hours .If BHCG level donot show increase of more than 50% within 48 hours need further investigations either in form of serial BHCG and TVScan monitoring or by diagnostic laparoscopy depending on clinical situation.Full blood count should be done as a baseline and to find if she need transfusion in case of surgical intervention for ectopic.Similarly ,blood group and Rh status and antibodies need to check as in case of surgical intervention she need injection Anti-D ,if she is Rh Negative. Conservative management of tubal pregnancy need certain criteria to be fulfilled.Patient should be asymptomatic and haemodynamically stable and initial BHCG level should be less than 1000iu/l or falling.On TVS ,size of adnexal mass should be less than 3 cm with absence of cardiac activity in the mass and fluid in pouch of Douglas should be less than 100 ml .The most important is that patient should be compliant to regular follow up and with easy access to hospital.If all these criteria are fuullfilled she should be properly counselled about followup and symptoms and need of surgical intervention any time during follow up and provided with hospital contact numbers .She will be followed up with twice weekly serum HCG levels and weekly Ultrasound .If serum BHCG levels falling and size of adnexal mass decreasing ,she can be follwed up with weekly BHCG levels and USG till serum BHCG below 20iu/l. Laparscopic treatment for ectopic pregnancy is associated with less analgesia requirement and less blood loss as compared to laparotomy.Duration of stay in hospital is less and early return to routine activities in case of laparoscopic treatment. Laparoscopic treatment is associated with less adhesion formation and lower recurrent ectopic rates than laparotomy for ectopic.Laparoscopic treatment of ectopic is cost effective . The disadvantage of laparoscopy is that laparoscopic expertise need a long learning curve and special equipment. Proper selection of patient is needed for laparoscopy to avoid complications that is obese patient and patients with previous history of intra abdominal surgeries or intra abdominal adhesions and peritonitis are not suitable for laparoscopy.Patient should be haemodynamicaly stable with no cardiovascular or respiratory compromise for laparoscopic management of ectopic.Site of ectopic is also important for laparoscopic treatment as corneal pregnancy best managed by laparotomy.There is increase chance of vascular injury and recourse to laparotomy in laparoscopic management.
		Posted by F N. Sun Jan 6, 2008 04:13 am
A) We advice for US examination to discriminate between intra-uterine and extra-uterine pregnancy with accurate estimation of gestational age. If pregnancy is intrauterine, US will determine viability also to differentiate threatened miscarriage from missed miscarriage. Viability is also important in extra-uterine pregnancy to decide method of treatment because presence of positive fetal heart activity carries high failure rate of medical or conservative treatment. Incomplete miscarriage can also be diagnosed by US, although this is unlikely because she didn\'t give history of expulsion of gestational product. US can diagnose molar pregnancy also. Serum HCG can help in diagnosing intrauterine pregnancy ( if the level is 1500iu or more , and the doubling time is 66% and more)from failed or extra uterine pregnancy. Cervical smear can detect coincidental causes of bleeding like cervicitis. B) She is at increased risk of rupture ectopic pregnancy with intra-abdominal bleeding and fainting. She will need urgent interference without previous preoperative preparation like fasting or blood grouping and saving, she may develop Mendelssohn syndrome. Also if the ectopic pregnancy ruptured; there will be no role for conservative or medical treatment. In view of these complications , this management is not justified. C) The advantage of minimally invasive surgery is rapid recovery and rapid return to work, this because of small post incisions and avoidance of laparotomy incision. Also there will be less incidence of wound heamatoma, wound infection and incisional hernia . In addition , there is less blood loss in the majority of laparoscopic surgery. In spite that there will be less incidence of intra-abdominal adhesion, yet there will be no difference in the rate of future intra-uterine pregnancy between laparoscopy and laparotomy. D) Laparoscopy can cause visceral injury (bowel and urinary tract), also it can cause blood vessel injury. This injury could be thermal due to Diathermy heat. It needs skilled operator and staff, also it needs a well equipped theater and good patient selection. It can lead to medistinal emphysema, mesenteric emphysema and sometimes subcutaneous emphysema.
		Posted by Srivas P. Sun Jan 6, 2008 06:08 am
(a) Routine investigations like complete blood, Blood group, urine routine and microscopic examinations should be done. At 8 weeks pregnancy a TV USG should be done for dating a possible viable intra uterine pregnancy. If there is no intrauterine pregnancy seen or there is adnexal mass, an ectopic pregnancy should be suspected and further investigations should be done. Serial B-HCG levels should be planned-its absolute levels, whether rising, plateau or falling. TV USG and Beta HCG levels itself may be enough to help decide treatment options in suspected ectopic gestations when woman is haemodynamically stable and she fits the criteria for medical or expectant treatment. Diagostic Laproscopy is not a must investigation unless she is haemodynamically unstable, has fluid in POD more than 100ml on USG suggesting ensuing tubal miscarriage. When the adnexal mass appears big with diameter> 3.5cm, the chances of medical treatment failure are high and she is a likely candidate for laproscopic treatment following diagnostic laproscopy. Serum progesterone levels are a useful investigation for medical management follow up as levels below 5ng/ml suggests a non viable pregnancy and likely success of medical or expectant treatment. (b)With a diagnosed ectopic pregnancy she has to fulfill criteria for medical or expectant treatment options to be allowed to go home with an appointment. This is possible only if she stays close to hospital and will come for follow up. She must be aware of signs of complications like faintness, giddiness and must have someone with her all the time to take her to hospital. This treatment is justified because with proper selection of case there is only 7-10% risk of subsequent surgical intervention. It is cost effective with only 50% cost of a laparoscopic treatment and the woman is able to return to work earlier. The results too are better-subsequent intra uterine pregnancy rate is 70% compared to 60-70% with laproscopic treatment while subsequent ectopic pregnancy too is lower at 10% compared to 18% with lap salpingostomy (c)Laproscopic salpingectomy is cost effective as compared to laparotomy as hospital stay is shorter, operative time is shorter, less need for analgesia and less blood loss. Subsequent intrauterine pregnancy rate is slightly better with laproscopic treatment compared to following laparotomy. Risk of subsequent ectopic pregnancy too is lower with laproscopic method. (d) Laproscopy is not advocated for unstable and haemorrhaging patients. Laprotomy is quicker and deals with massive haemorrhage more effectively. Laproscopic method needs highly skilled operator. Risk of persistent trophoblast is more with laproscopic method 8% compared to 4% with laparotomy-- that is with laproscopy there is more need for further follow up and treatment. In this woman with prior PID there are likely to be intraabdominal adhesions which makes a laparotomy a safer option-lesser risk of injury to bowel or blood vessels.
		Posted by S M. Sun Jan 6, 2008 08:53 am
A 30 year old woman with a history of pelvic inflammatory disease and sub-fertility is referred to the early pregnancy clinic with 8 weeks amenorrhoea, a positive pregnancy test and a brown vaginal discharge. She is haemodynamically stable. (a) Justify your initial investigations [5 marks]. (b) A right tubal ectopic pregnancy is identified. She is discharged home with a follow-up appointment. Justify this management [5 marks]. (c) She subsequently undergoes laparoscopic salpingectomy. What are the advantages of laparoscopic treatment compared to laparotomy [5 marks]? (d) What are the disadvantages of laparoscopy compared to laparotomy [5 marks]? a) A full blood count must be done to ensure that she is not anaemic which may be due to internal bleeding from an ectopic. A group and save is essential, in case an emergency operation needs to be done for an ectopic. Also, if the blood group is negative, anti D will need to be given if it is an ectopic or later in an intrauterine pregnancy with bleeding. A serum beta HCG test will measure the level of beta HCG present. This allows us to compare it to subsequent values and to determine whetehr it is an ectopic, viable or failing intrauterine pregnancy. Endocervical swabs for chlamydia and gonorrhea should be done to identify these infections, since there was a history of pelvic inflammatory disease. These infections would need to be treated since they can cause an adverse preganancy outcome or worsen if instrumentation or an operation is required in the future. An ultrasound scan should be done in order to identify the location, size and viability of the fetus. b) Conservative management at home is apprpriate in some circumstances. A woman without pelvic or abdominal pain, dizziness, light headedness or shoulder tip pain can be allowed home since she is asymptomatic for an ectopic pregnancy. She is haemodynamically stable. If there is no abdominal distension, rigidity or tenderness, this suggests that the ectopic is small, resolving or not ruptured. The likelihood of the ectopic rupturing is low. However, she should be given a clear explanation of what an ectopic pregnancy is, the risks involved and the symptoms that she may experience. If this occurs she should come to the hospital immediately. This woman would be more comfortable in her home than in the hospital. The hospital bed can be used for another patient. The follow up visit will allow for review of her symptoms and signs, and also a serum beta HCG done 48 hours after the first test. If the value is increasing, then medical or surgical treatment is required. If the value decreases and she remains asymptomatic then conservative management is appropriate. c) Laparoscopic treatment results in a shorter hospital stay than laparotomy. With laparoscopy, there is less morbidity. Cosmetically it is better since there may only be 3 small incisions, compared to the longer laparotomy scar. With future operations, there would be less scarring and adhesions to deal with, compared to a laparotomy. d) The disdavantages are that more advanced specialist training is required for laparoscopic salpingectomy compared with laparotomy. It does not allow for as much access as the laparotomy incision. There is a risk of bowel or vessel injury from blind laparoscopic entry. If there is bowel injury, this would then lead to a laparotomy, risks of thromboembolism and an even longer hospital stay. It is not suitable for cases of ruptured ectopic.
		Posted by N S. Sun Jan 6, 2008 10:29 pm
a) In the above mentioned case I would like to request for the serum beta hcg level because of the possibility of ectopic pregnancy. Blood group to check if the patient is Rh negative then she may require Anti-D injection if any operative procedure is undertaken e.g evacuation of retain products of conception or laparoscopy for ectopic pregnancy. I will also advice the blood bank to save the sample for future cross match if required. Ultrasound to check for the location of the pregnancy .Full blood count to assess the initial haemoglobin of the patient . b) In case where right tubal ectopic is identified in a haemodynamically stable patient, the patient can be discharged with follow up appointment if the serum b.hcg level is <1000 , the adnexal mass does not show any cardiac activity , there is no free fluid in the abdominal cavity on scan. Also important that before discharge the patient is aware of the potential risk of the rupture ectopic pregnancy .She should me made aware of the sign and symptom for example fainting , shoulder tip pain and sudden onset pain in lower abdomen. Pt should have access to transport in event of emergency and the hospital providing the expectant management service is capable of dealing with emergency. c) Compare to laparotomy which is the operation of choice in a haemodynamically unstable patient, where a bigger incision is required to perform the operation to achieve quick haemostasis, The advantage of laparoscopic surgery are cosmetically acceptable to young patient, less post operative pain , shorter hospital stay, quick recovery . Also at time of laparoscopic surgery the surgeon can look at the other viscera to exclude any other abnormalities. d) Compare to laparotomy where the disadvantage are bigger scar, more post operative pain , longer hospital stay, delayed recovery. The Laparoscopic surgery is associated with the high risk of damage to blood vessels and damage to bowel. There can be difficulty in operation if multiple dense adhesion are found in abdominal cavity. Risk of converting the laparoscopic procedure to laparotomy if difficulty in achieving haemostasis. The lack of availability of experienced surgeon is important to perform the laproscopic procedure.
		Posted by Farina A. Mon Jan 7, 2008 01:53 am
a) My initial investigation will include a CBC, blood grouping, RH typing, cross matching to see the Hb levels because this patient may require possible blood transfusion and anti-D immunoglobulins. A quantitative β HCG for confirmation of a pregnancy and to have an idea about the gestational age. However a single β HCG value is less helpful compared to serial measurements. For a normal intrauterine pregnancy the β HCG doubling time is 1.5 days but variation may occur. Failure of doubling of β HCG in 1.5 days suggest a failing intrauterine pregnancy or an ectopic pregnancy. Transvaginal ultrasound can detect a pregnancy as early as 4.5 weeks from the LMP so it is sufficiently sensitive investigation to detect the location and size of the gestational sac. Some authorities suggests serum progesterone concentrations which may be helpful in correlation with clinical presentations and the above mentioned investigations. A falling concentration may support the diagnosis. b) Those ectopic pregnancies in which β HCG is 1000iu or less and is falling with minimal fluid in pouch of Douglas can be managed conservatively and as out pts, provided the women is fully informed about the diagnosis,the management, its risks, benefits, and available alternatives. There should be enough resources for the women to contact the medical personnel when symptoms arise. Providing written information is advisable. c) Advantages of laproscopic treatment includes, good cosmetic results magnified and panoramic view of the abdominal cavity, less intraoperative haemorrhage and postoperative pain, stay in hospital and earlier return to work. Minimal postoperative adhesion formation and complications related to adhesion like future ectopic pregnancy and bowel obstruction. d) Disadvantages to laproscopic treatment compared to laprotomy includes need of expertise and proper equipment handling, need of adequate staff specially trained in this speciality. Safe entry is one of the major concern as there are chances of damage to the major vessels and bowel specially in cases where there is history of previous abdominopalvic surgery. Inadvertant injury to the surrounding structures especially conduction injuries to the visceras out of vision is also an additional complication. Persistant trophoblastic tissue is one of the recogniseed drawbacks of laproscopic salpingiostomy.
		Posted by Mahmud K. Mon Jan 7, 2008 10:09 am
Full blood count for baseline haemoglobin to assess anaemia and further rapid fall of haemoglobin may indicate internal haemorrhage. Group and save should be done for future rapid blood transfusion.Her Rhesus status should be known for antiD immunoglobulin administration may required after surgical intervention.Transvaginal ultrasound scan is useful for determine the site , size and viability of pregnancy. So it helps to detect ectopic, intrauterine , pregnancy of unknown location and also missed miscarriage.Serum BHCG should be done. The use of BHCG to select patients for expectant , medical and surgical management of ectopic pregnancy and to assess the efficacy of treatment at follow up. Expectant management justified for asymptomatic women with certain ultrasound diagnosis of ectopic,no evidence of haemoperitonium, no evidence of fetal cardiac activity, adenexal mass less than 5 cm, initial BHCG levels less than 1000iu/L The progress of ectopic pregnancy is easier to monitor as rising levels indicating an increased risk of rupture. Active management if symptomatic so she should be able to comply with close follow-up and should have easy access to hospital. Laparoscopic treatment has shorter operation time. There is less intraoperative blood loss, shorter hospital stays,lower analgesic requirements and development of less adhesions. .There is lower repeat ectopic pregnancy rates at laparoscopic approach. It is not suitable for haemodynamicaly unstable patients. Experienced surgeon and equipment needed. Small risk of tubal bleeding in the postoperative period and potential need for further treatment for persistent trophoblast in laparoscopic salpingostomy.
		Posted by F N. Mon Jan 7, 2008 07:18 pm
Dear Dr Paul Good Day to you Many people need a hand in improving their performance, one of them is me. In respect to this essay, I want to clear up the following please: 1)although the history given of PID and sub fertility , this patient may have : threatened miscarriage , missed miscarriage, resolved pregnancy , pregnancy of uncertain viability and less likely incomplete miscarriage . If a question like this appear in exam , we can not be certain it is asking about Ectopic pregnancy specifically and leaving the other differential diagnosis,how can we assume it is an Ectopic pregnancy essay only ? therefore nt all cases will need doubling time or diagnostic laparoscopy ! 2)with regard to justification of management, doesn\'t that mean we should mention advantages and disadvantages of expectant management, it is not explanations of the expectant management , what we do and how to follow the patient. I appreciate the Good answer given before me and I saw that you give it a score 4/5 and the answer give only 2 disadvantages of expectant management , which is the need for good patient compliance and the possibility of urgent surgery. I admit that I gave a poor and disorganized answer, please I will be so grateful if you reply to my questions Thanks and maintain blessed.
		Posted by F N. Mon Jan 7, 2008 07:28 pm
I forget also to mention that I assume expectant management is not justified because she had 8 weeks period of amenorrheao , and this mean incidence of rupture is high 3) my third confusion , do we depend only on us features like adnexal mass size, fetal heart activity, or we take in our consideration the period of amenorrheao ? Thank you.
		Posted by N S. Mon Jan 7, 2008 07:48 pm
Dr Paul Could you please check my answer .Thanks All answers are marked on a first-come-first-served basis and within 72h of posting
		Posted by F N. Mon Jan 7, 2008 11:38 pm
Thank you very much.
		Posted by Hala T. Tue Jan 8, 2008 02:25 am
a)The history and clinical findings are suggestive of unruptured ectopic pregnancy.The delay in diagnosis carries the risk of rupture. The initial investigations should follow the protocol unit. The combined serial serum BHCG and transvaginal ultrasound are required to establish definite diagnosis. Unit specific discriminatory zone for serum hcg should be defined to exclude ectopic pregnancy. At levels of 1500 IU/ L , an ectopic will be visualised by T.V.S. If concentration below discriminatory zone , there is possibility of early intrauterine pregnancy and hcg should be repeated 48 hrs later. A rise of HCG of > 66 % is suggestive of an intrauterine pregnancy and T.V.Scan should be repeated 7 days later. A rise of HCG < 66 % is suggestive of an ectopic. Further investigations should follow unit protocol and include a consideration of any new symptoms. FBC ,blood group ,and crossmatching for saving blood.Rh status should be determined for Anti-D to be if she is unsensitized rhesus negative. b) Expectant management is justified for haemodynamicaly stable ,asymptomatic with a decreasing serum HCG, initially less than 1000 IU/L. The ectopic sac should be less than 5 cm with no FH detected on scan and with no or less 100 ml free fluid in pouch of Douglas. Twice weekly serial HCG and weekly T.V.S. should be performed to ensure rapidly decreasing HCG level ( ideally < 50 % of its initial level within 7 days and reduction of adenxal mass by 7 days. Thereafter , weekly HCG and T.V.S. advised until HCG level < 20 % . There is a case reports of tubal rupture at low level of HCG. The woman should be provided clear written information on the importance of compliance with follow-up . She should be able to return easily for assessment during follow-up. c) Laparoscopic salpingectomy is superior to open surgery in terms of reduced surgical trauma to anterior abdominal wall resulting in quicker recovery and reduced hospital stay. Laparoscopic treatment ,also, has the advantage of lower intra-operative blood loss , lower rate of adhesions formation and lower analgesics requirement .It is more cost-effective. Laparoscopic treatment has subsequent similar intrauterine pregnancy rates, and a lower repeat ectopic pregnancy rates . d)The disadvantages of laparoscopic treatment is increased requirements of resources ,equipements and adequate training .Vascular damage is another disadvantage ,mainly to aorta,vena cava , pelvic vessels and inferior epigastric vessels ,if lateral port is used. Bowel injury is another disadvantage and especially if it is unrecognized intraoperatively. It carries the risk of development of peritonitis.Laparoscopy is not suitable for haemodynamically unstable patient.
		Posted by Dr seema jain J. Tue Jan 8, 2008 04:25 am
a) Trans vaginal Ultrasound and the serum beta hcg levels form the cornerstone in case of an early pregnancy. The doubling of serum beta hcg (66% in 48 hours) may be helpful in differentiating between an intrauterine & ectopic pregnancy. Trans vaginal Ultrasound is important in the diagnosis of an intrauterine/ectopic/heterotopic or a molar pregnancy & associated organic pathology (ovarion cyst, fibroid if any). The basel serum beta hcg in case of a molar or multiple pregnancy may be higher than expected. Around 10 ? 20% of early pregnancies can be ?pregnancy of unknown location?. In such cases, serum monitoring of serum beta hcg and progesterone levels may be done to decide upon the management. Routine blood tests like complete blood count (to detect anemia) & blood group and Rh typing including screening for atypical antibodies (for Rh allo-immunisation) needs to be done. Screening for infections include testing for HIV, Hepatatis B, syphilis are done, if pregnancy is intrauterine. A high vaginal swab should be done in this case since she is a known case of PID. b) Expectant Management of a tubal pregnancy in this case has been considered since she is hemodynamically stable. The other criteria for expectant management include serum beta hcg levels of less than or equal to 1000 miu per ml or falling beta hcg levels, gestational sac of < 3 cms and < 100 ml of fluid in pouch of Douglas. Expectant Management is considered only if the patient is deemed to be compliant. She should be given all the emergency contact numbers and easy access to hospital facilitated. She should be given a written information leaflet and explained about the need for immediate visit to the hospital in case of signs of rupture. Twice weekly beta hcg and a weekly trans vaginal scan should be arranged for.She should be advised to not to travel to remote places. c) Laparoscopic management of ectopic pregnancy involves normally only a day?s stay at the hospital which reduces the cost to the hospital. It is also cost effective to the patient since it lessens the number of absent days from work and the expense in case extra help is required. The operating time and the post operative adhesions with laproscopy are much lower than laprotomy. The post operative recovery is faster and the pain lesser after laproscopy. The amount of blood loss is lesser in laparoscopic surgery. d) Unlike laparoscopy, laparotomy does not require specialized skilled personnel trained in laproscopy. There is no need for expensive special equipment which is needed for laparoscopy. The incidence of fatal injuries (vascular and visceral) in case of laparotomy is lower than laparoscopy. Laparotomy is a procedure of choice in case of an interstitial pregnancy. Ina hemodynamically unstable patient, laparotomy is the preferred choice. In women who are anticipated to have adhesions(as in this patient who is a case of PID) laparotomy is preferable.
		Posted by hoping .. Tue Jan 8, 2008 06:24 am
ectopic pregnancy needs to be excluded because of high possibility in this patient, other possibilities are threatned misscarriage, infection, molar pregnancy, cervical or lower genital tract pathology. Investigations would include FBC- to check Hb because of possibility of ectopic pregnancy and risk of rupture, risk of heavy bleeding with miscarriage and should be available if surgical intervention is required for any reason, early determination of low Hb will enable timely crossmatch.Lecocytosis may indicate infection. Blood group determination for saving and crossmatch and antiD may be required later,serum beta hCG aids in diagnosis especially when USS findings are inconclusive, serial measurements help in management of ectopic pregnancy, pregnancy of unknown location and pregnancy of uncertain viability, also may be first indication of molar pregnancy. Swabs for infection, colposcopy may be indicated . TV USS( trans abdominal USS can be offered althogh less sensitive in very early gestation) to assess viability, location of pregnancy . conservative management of known ectopic pregnancy can be justified here as patient is stable, has no symptoms of pain or impending rupture provided strict protocol is followed, it is informed decision, patient is aware of risk of intervention, possibiity of rupture, warning symptoms and is in approachable distance. serum hCG levels below 1000. small sac and no evidence of blood in peritoneal cavity, Information should be strengthened with leaflets and documented in notes. Conservative option may avoid need for surgery and intraoperative risks with surgery and if sucessfull will have comparitive lower negative effect on future fertility. laparoscopic management of ectopic has advantages of lower risk of bleeding requiring transfusion, short hospital stay, quicker recovery,less pain, cosmeticaly better scar, less adhesions, better subsequent intrauterine pregnancy rates. its disadvantages include higher risk of visceral injury especially if there are adhesions from PID, may not be option if quick access is required , cornual pregnancy, previous midline laparotomy.It can fail when mobility of viscera restricted or failure to gain access into peritineal cavity, reduce visibilty when severe bleeding, equipment failure.
		Posted by Idris O. Wed Jan 9, 2008 08:16 am
a)Initial investigations include FBC to determine her haemoglobin. I would arrange a grouping, rhesus antibody status and save because may require surgery, blood transfusion and anti-D prophylaxis . I would check her serum B hcG to determine baseline and suitability for any form of treatment offered. I would check her serum progesterone levels which may suggest if the fetus is viable or not and also helps with counselling for treatment options. A transvaginal USS is the goal standard in diagnosis especially if BhcG is > 1,500 IU/l. It would confirm the site of the ectopic pregnancy and the absence of IUP. It would also show the site of the ectopic as cornual pregnancy is a contraindication to medical or laparoscopic treatment. The presence of cardiac activity or gestational sac > 4cm is a conytaindication to conservative or medical treatment. b)This is more likely to be an ectopic pregnancy where she?s haemodynamically stable ( PR, BP and Hb are Normal). The BhcG is more likely to be <3000 IU/l and the serum progesterone < 25nmol/l showing non-viable pregnancy.There is no likelihood of cardiac activity and the gestational sac is < 4cm. There is liitle or no haemoperitoneum. This patient must be readily available for follow up and should be aware of signs and symptoms suggestive of progressive disease like increasing abdominal pain or dizziness requirinq prompt return to the hospital. She would be reviewed in 48h with repeat serum BhcG to demonstrate resolving ectopic pregnancy with a fall of at laest 15% in BhcG.. An information leaflet would be provided to this patient . The telephone no of a 24h dedicated EPAU would also be provided in case help is required at short notice. c)Advantages of laparoscopic treatment compared to laparotomy includes reduction in intra-operative blood loss and reduced need for transfusion. There is also reduction in operating time with quicker post operative recovery . This leads to shorter hospital stay. There is usually a very small scar with reduced need for post operative analgesia. There is a comparable intrauterine pregnancy rate . There is early post operative recovery with early return to work . This is associated with improved patient?s satisfaction. d) The disadvantages of laparoscopy compared with laparotomy is that there is also an increased risk of visceral injury like, bowel, bladder and vessel which may require laparotomy for treatment. Extensive pelvic adhesions may make access by laparoscopy impossible. It may not be suitable for all patients like ruptured ectopic with hypotension and shock. It is contraindicated with cornual ectopic pregnancy due to risk of bleeding. . Additional contra-indication in patients with cardiovascular and respiratory problems due to difficulty with pneumoperitoneum It requires skill and training in the use of sophisticated equipment.
		Posted by Toyin A. Mon Jan 14, 2008 09:35 am
a) Initial investigations include history,clinical examination,blood tests and imaging. In the history,her history of pelvic inflammatory disease increases the risk of this being an ectopic pregnancy.Any history of abdominal pain may point towards an ectopic pregnancy rather than an intrauterine pregnancy. Clinical examination to elicit any signs of an ectopic such as abdominal tenderness,adnexal tenderness,cervical excitation.Also a miscarriage may be diagnosed if an open cervical os or products of conception are seen at this stage. Blood tests such as full blood count for haemaglobin,and blood group for rhesus status and save serum for any operation that may be needed.Serum beta HCG and serial measurements will aid in diagnosis of ongoing intrauterine pregnancy,failing intrauerine pregnancy or an ectopic pregnancy. Imaging by transvaginal pelvic scan will confirm an intrauterine pregnancy,viable or not,and will aid diagnosis of an ectopic if any adnexal mass,free fluid,empty uterus are seen. b) This management is conservative or medical and is suitable as she is haemodynamically stable.She would need to be given written information and instructions to return if anything changed clinically and have 24hour access to the gynaecology team if her clinical condition changes.She would need to be informed that if she deteriorates she would need surgical intervention. This management is justifiable if her initial serum beta HCG is low(<1000),the ectopic size on scan is small(<3cm)with no cardiac activity or significant free fluid seen.She could have the medical option of intramuscular methotrexate aswell. c)Advantages of laparoscopy include shorter hospital stay,less analgesia post operatively,shorter recovery time,less cost,more acceptable to patient/better cosmetic result,less risk of adhesion formation,less blood loss. d) Disadvantages of laparoscopy include the need for a suitably trained surgeon and theatre staff,specific operating instruments,increased risk of visceral damage eg bladder or bowel or ureteric injury,increased risk of vascular damage,conversion to laparotomy if complications occur intraoperatively.