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Ectopic Pregnancy - Coggle Diagram

- - - - PID
      - Endometriosis
      - Pelvic surgery
      - Sterilisation
      - Previous ectopic pregnancy treatment
  - - - Stable
      - Unstable
    - - Fallopian tube 95%
        
        Fimbriae 10%
        
        Infundibulum ampulla 70%
        
        Interstitium 5%
      - CS scar
      - Cervix
      - Peritoneal cavity - abdominal pregnancy
      - Ovary
      - Heterotopic - rare
        Simultaneous dvelopment of intrauterine pregnancy and an eptopic pregnancy
  - - - Decreased - better diagnosis & management -
        TVUS / HCG blood tests / EPAU
        Laparoscopic managment
- - - - Missed period
      - Lower abdominal pain
        Colicky visceral pain (tubal spasm)
        Constant localised perietal pain (intraperitoneal bleeding)
      - Syncope / collapse
        (shock from bleedin)
      - Shoulder tip pain
        (Intraperitoneal bleeding irritating diaphram - referred pain phrenic nerve)
      - Lower GI symptoms - Diarrhoea
        (Bowel irritation from bleed)
      - Vaginal bleeding - small amount, dark colou
        (from HCG causing thickened endometrium - decidua)
      - May be asymptomatic
    - - Patient details: Advanced maternal age
      - PMHx:
        Conditions damaging fallopian tubes (PID, endometriosus)
        Previous ectopic pregnancy
        Contraception use
        Fertility wishes, plans, treatments
      - SH:
        Smoking
    - - Pregnancy dating
      - LMP and date certainty
      - Regularity, duration
      - Positive pregnancy test date
      - Contraceptive use
  - - - Unwell
      - Pale
      - Unresponsive - shock
    - - Tachycardia
      - Hypotension (shock)
    - - Superficial tenderness / gaurding - bleeding
      - Rigidity - bleeding
      - Rebound tenderness - acute abdmen
      - Deep palpation - ectopic mass
    - - Closed cervical os
      - Small amount of bleeding
    - - Adnexal tenderness
      - Cervical motion tenderness
      - Adnexal mass
  - - - Urinary HCG
    - - Serum HCG
    - - TVUS
        
        Findings in EP
        
        No intrauterine pregnancy - empt pregnancy
        
        Adnexal mass
        May be tissue mass or discrete gestational sec wtih fetal pole and heart beat - often EP is not visible
        
        Free fluid
        If intraperitoneal bleeding
        
        May not visualise an EP on TVUS
        
        Findings in healthy IUP (intrauterine pregnancy)
        
        Gestational sac
        from 4.5 weeks
        
        Yolk sac
        from 5 weeks
        
        Fetal pole with fetal heart beat - viable
        from 5 weeks
    - - Laparoscopy
      - Invasive and usually not required - used for treatment
    - - FBC - anaemia
      - G&S or crossmatch - blood transufion
  - - - Serum HCG
        
        PUL + Absolute HCG level ≥ 1,500 IU/L
        
        Likely Ectopic pregnancy
        
        PUL + Serial HCG levels show suboptimal rise over 48hrs
        ( <2/3rds rise or <1/2 fall)
        
        Likely ectopic pregnancy
        
        PUL + serial HCG levels show optimal rise over 48hrs (>2/3rd rise)
        
        Likely intrauterine pregnancy (IUP)
      - Hx + Exam
  - - - Viable IUP
      - Miscarriage
        
        Missed
        
        Incomplete
        
        Complete
      - Molar pregnancy
    - - +PT but
        no IUP / EP / RPOC on TVUS
- - - - Inhibition of DNA and RNA synthesis
        Particularly effective against tophoblastic cell proliferation
    - - Clinical:
        Stable
        No pain
      - TVUS:
        Adnexal mass < 35mm
        No Fetal Heart activity
        No free fluid
      - HCG level<1,500 IU/L
    - - Single IM injection
    - - Benefits
        
        Effective treats 90%
        
        Preserves fallopian tubes
        
        Avoids surgical risks
      - Disadvantages
        
        Failure requireing injection (15%) or surgery (10%)
        
        Longer treament interval - weeks
        
        Side effects (eg abdo pain)
    - - Weekly HCG untill HCG negative (<20)
      - Advise reliable contraception for 3 months
    - - Outpatient
  - - - Clinical
        Unstable
        Pain
      - TVUS
        Adnexal mass ≥ 35mm
        FH activity
        Free fluid
      - HCG level
        ≥ 5,000 IU/L
    - - REmove Fallopian tuve containing EP (salpingectomy)
    - - Benefits
        
        Effective treats 100%
        
        Short treatment interval
      - Disadvantages
        
        Invasive
        
        Associated with surgical risk
    - - Urinary HCG after 3 weeks
    - - Laparoscopic > Laparotomy
      - Salpingotomy
        
        Consider if contralateral tube is damaged
        
        Higher recurrent EP risk
      - Salpingectomy
        
        f contralateral tube is healthy
        
        Lower persistent trophoblastic risk
        
        Removal of tube - ovary untouched
        
        Similar fertility rates for ectomy vs otomy
    - - Inpatient
  - - - No pain AND HCG level <1,000 IU/L and decreasing
    - - Serum HCG level until negative
  - - - Measure vitals
    - - Get anaesthetist / gynaecologist
    - - Position falt
      - Give O2
      - Secure IV acess
      - Give IV fluids
      - Urinary catheter
    - - Give blood
    - - Laparoscopic salpingectomy