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Ectopic Pregnancy - Coggle Diagram
Ectopic Pregnancy
Differential Diagnosis
Urethral bleeding
Haemorrhoids
Pregnancy-related degeneration of a fibroid
Trauma of the cervix, vagina, or vulva
Ruptured ovarian corpus luteal cyst
Cancer of the cervix, vagina, or vulva.
Molar pregnancy
Vaginitis
Miscarriage
Cervicitis, cervical ectropion or cervical polyps
Muscluloskeletal pain
Constipation
Urinary tract infection
Irritable bowel syndrome
Pelvic inflammatory disease
Appendicitis
Renal colic
Bowel obstruction
Adhesions
Torsion of a fibroid
Ovarian cyst
Pelvic vein thrombosis
Risk factors
Cigarette smoking
Maternal age over 35 years
Assisted reproduction techniques
Having multiple sexual partners
History of infertility
Contraception - failure of contraception risk will depend on method used.
Damage to fallopian tubes from previous inflammatory disease or surgery
Previous ectopic pregnancy
Management: Follow up
Give opportunity to discuss any questions about ectopic pregnancy.
Assess women's psychological well-being and offer appropriate counselling.
Cancel arrangement for routine antenatal care
Advise to inform GP asap about any future pregnancy for ultrasound to be arranged to establish location and viability of the pregnancy.
Give advice on appropriate contraception
Ensure that all rhesus-negative women who have had surgical removal of an ectopic pregnancy have received anti-D immunoglobulin.
Provide sources of additional information and support on ectopic pregnancy.
Mangement: Suspected ectopic pregnancy
No abdominal pain/tenderness - perform gentle pelvic examination - do not palpate for adnexal or pelvic mass as this may increase risk of rupture - if tenderness - strongly suspect and arrange immediate admission.
If less than 6 weeks pregnant with bleeding and no pain - advice to repeat urine testing after 7-10 days and return if test is positive/symptoms continue or worsening (then refer to Gyn). Negative testing means pregnancy has miscarried.
Perform gentle abdominal examination - pain/tenderness strongly suspect ectopic pregnancy arrange immediate admission.
Arrange urine pregnancy testing (if pregnancy confirmed assess for signs of ectopic pregnancy)
Gynaecology referral - explain reason for referral and what to expect when arrive (transvaginal ultrasound for diagnosis) (treatment includes expectant management/medical management) and arrange follow up/support.
Arrange immediate ambulance transfer if any signs of haemodynamic instability (pallor, tachycardia, hypotension, shock, collapse). Resuscitate with IV fluids if available. Or if there is significant concern about degree of bleeding/pain.
Diagnosis: Symptoms
Less common: breast tenderness, GI symptoms (diarrhoea/vomiting), dizziness, fainting, syncope, shoulder tip pain, urinary symptoms, passage of tissue, rectal pressure or pain on defecation.
Symptoms generally appear 6-8 weeks after last normal menstrual period (or much later for a non-tubal ectopic pregnancy)
Common: Abdominal or pelvic pain, amenorrhoea or missed period, vaginal bleeding (with or without clots)
Risk factors may or may not be present.
Diagnosis: Examination
Less common signs: cervical motion tenderness, rebound tenderness or peritoneal signs, pallor, abdominal distention, enlarged uterus, tachycardia or hypotension, shock or collapse, orthostatic hypotension
Common signs: abdominal tenderness, pelvic tenderness, adnexal tenderness
Confirm with pregnancy test
Tubal Rupture and Intra-abdominal bleeding
Shoulder pain - may be caused by irritation of the diaphragm due to leakage of blood from the implantation site
Pallor, tachycardia, hypotension, shock or collapse may indicate tubal rupture/severe bleeding
Vomiting and diarrhoea - may be presenting symptoms
Definition: An ectopic pregnancy is a pregnancy that implants outside the uterine cavity - it can occur in the fallopian tube, ovary, abdomen, cervix, caesarean section scar, interstitial part of the fallopian tube or at the cornua of a unicornuate or bicornuate uterus.
A heterotopic pregnancy is the coexistence of both an intrauterine pregnancy and an extrauterine pregnancy.
Many diagnosed have no identifiable risk factors.