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Ectopic pregnancy

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Katie Zhu

on 25 November 2014

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Transcript of Ectopic pregnancy

Sarah Smith
Ectopic Pregnancy
Zygote implants outside uterus

1.2 - 1.4% of all pregnancies

Accounts for 9% of all pregnancy related deaths

Cesarean scar
Amniotic sac
Rupture site
Fetal Length
distended fallopian tube
Inhibits DHFR to interfere with purine and amino acid synthesis
92% success rate
Local (IM) or systemic (IV) injection
Single vs. Multiple doses
Monitor hCG


Side effects

Nausea and vomiting
Abdominal pain
Impaired liver function tests
Protuding fetus

In vitro fertilization
(2 months prior)
Smoker (5 years)
Otherwise healthy

Factors impacting future pregnancy:
36 years old
Chief Complaints
Severe abdominal pain
Cramping near pelvis
Vaginal bleeding
Dizzy and lightheadedness
Onset in the last hour
Normal Implantation
Cyst of Morgagni
Ampullary Rupture
Interstitial Rupture
decreased rate

- decreased
serum level
65-75% fertility rate 2 yrs post EP
30% of females with tubal pregnancy cannot subsequently conceive
10-27% risk of recurrent EP
1. Presence of tubal abnormalities (scarring)
2. Age > 35
3. History of intrauterine births
Work Cited

Retrieved from: http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Information_Booklets/Ectopic_Fig5.png
Retrieved from: http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Information_Booklets/Ectopic_Fig4.png
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HTHSCI 4K03 Pathophysiology

Module prepared by:
Chelsea Mackinnon
Teagan Telesnicki
Jordyn Vernon
Katie Zhu

Narrated by:
Chelsea Mackinnon

Special thanks to:
Dr. Thomas Hawke
Dr. Radenka Bozanovic
Michael Romaniuk
Dr. Bruce Wainman

1. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG, et al. Chapter 7. Ectopic Pregnancy. Williams Gynecology, 2e. New York, NY: The McGraw-Hill Companies; 2012.
2. Cecchino GN, Araujo Junior E, Elito Junior J. Methotrexate for ectopic pregnancy: when and how. Archives of gynecology and obstetrics. 2014;290(3):417-23.
3. Wainman B. Reproductive Physiology II [unpublished lecture notes]. HTH SCI 2FF3: Human Anatomy and Physiology II, McMaster University; lecture given April 4, 2013.
4. Norwitz ER, Schust DJ, Fisher SJ. Implantation and the survival of early pregnancy. N Engl J Med. 2001 Nov 8;345(19):1400–8.
5. Tortora GJ, Derrickson B. Principles of anatomy and physiology. 12th ed. Hoboken: John Wiley & Sons Inc; 2009.
6. Kumar V, Abbas AK, Aster JC. Robbins and Cotran pathologic basis of disease. 9th ed. Philadelphia: Elsevier Saunders; 2015.
7. Standring S. Gray’s anatomy. 40th ed. London: Elsevier Ltd; 2008.
8. Rana P, Kazmi I, Singh R, Afzal M, Al-Abbasi FA, Aseeri A, et al. Ectopic pregnancy: a review. Archives of gynecology and obstetrics. 2013;288(4):747-57.
9. Farquhar CM. Ectopic pregnancy. Lancet. 2005; 366:583-591.
10. Klatt EC. Robbins and Cotran atlas of pathology. 2nd ed. Philadelphia: Elsevier Saunders; 2010.
11. Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. Elsevier; 1997;67(3):421–33.
12. Varma R, Mascarenhas L. Evidence-based management of ectopic pregnancy. Current Obstetrics & Gynaecology. Elsevier; 2002;12(4):191–9.
13. Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and “multidose” regimens. Obstet Gynecol. 2003 Apr;101(4):778–84.
14. Varma R, Gupta J. Tubal ectopic pregnancy. Clin Evid (Online). 2012;2012.
15. Alkatout I, Honemeyer U, Strauss A, Tinelli A, Malvasi A, Jonat W, et al. Clinical diagnosis and treatment of ectopic pregnancy. Obstetrical & Gynecological Survey. 2013 Aug;68(8):571–81.
16. Capmas P, Bouyer J, Fernandez H. Treatment of ectopic pregnancies in 2014: new answers to some old questions. Fertility and Sterility. American Society for Reproductive Medicine; 2014 Mar 1;101(3):615–
17. de Bennetot M, Rabischong B, Aublet-Cuvelier B, Belard F, Fernandez H, et al. Fertility after tubal ectopic pregnancy: results of a population-based study. Fertility and Sterility. Elsevier Inc; 2012 Nov 1;98(5):1271–3.
18. Butts S, Sammel M, Hummel A, Chittams J, Barnhart K. Risk factors and clinical features of recurrent ectopic pregnancy: a case control study. Fertility and Sterility. 2003 Dec;80(6):1340–4.

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1. Which of the following symptoms is NOT associated with ectopic pregnancy?
a. Abdominal pain and tenderness
Incorrect: Abdominal pain and tenderness would occur as a result of fallopian tube distention, rupture, and subsequent hemorrhage
b. Confusion
Incorrect: Confusion would be present as it is a symptom of shock, which may occur as a result of blood loss due to tubal rupture
c. Heavy vaginal bleeding
Correct: Even in the case of tubal rupture, blood would leak into the abdominal cavity and would not be lost in large quantities through the vagina. However, light vaginal bleeding or spotting may occur.
d. Dizziness
Incorrect: Dizziness may occur as a result of blood loss secondary to tubal rupture, and is also a common side effect of normal pregnancy.

Quiz 1.
2. In a normal pregnancy, where is the ideal place for a zygote to implant?
a. Isthmus of fallopian tube
Incorrect: The fallopian tube is not large enough to accommodate a growing embryo and placenta, and would rupture with time.
b. Fundus of the uterus
Correct: Implantation in the fundus of the uterus ensures that the growing trophoblast and placenta do not block off the cervix.
c. Top of the cervix
Incorrect: Implantation in this location would result in blocking of the cervix as the trophoblast and placenta begin to grow.
d. Anywhere within the endometrium
Incorrect: Theoretically, the zygote can implant anywhere in the endometrium to have access to maternal blood supply, but the fundus is the most ideal location.

3. Where is the most common location for an ectopic pregnancy to implant?
a. Interstitial
Incorrect: Implantation in the interstitium occurs in only 2.5% of cases.
b. Tubal ampullary
Correct: 95% of ectopic pregnancies implant in the fallopian tube, with 75-80% of these implanting specifically in the ampullary region.
c. Tubal isthmus
Incorrect: Although 95% of ectopic pregnancies implant in the fallopian tube, only 10-15% of these are in the isthmic region specifically.
d. Ovarian
Incorrect: Implantation in the ovary occurs in only 0.15-3% of cases.

1. Which of the following is NOT a risk factor for ectopic pregnancy?
a. In vitro fertilization
Incorrect: In vitro fertilization increases the risk of ectopic pregnancy as the implanted zygote may be placed too high in the uterus, thus allowing for wandering and implantation in an ectopic location.
b. Chlamydia
Incorrect: Chlamydia infection can cause scarring in the fallopian tubes, which would increase the risk of ectopic pregnancy.
c. Previous abdominal surgery
Incorrect: Previous abdominal surgery may have caused scarring in the fallopian tubes, which would increase the risk of ectopic pregnancy.
d. Previous pregnancies
Correct: Previous pregnancies do not increase the risk of ectopic pregnancy.

2. In a suspected ectopic pregnancy you would expect the blood results to show...
a. Abnormally elevated progesterone levels
Incorrect: Progesterone levels would be lower than usual in an ectopic pregnancy.
b. Unchanging hCG levels
Incorrect: hCG levels may still increase in ectopic pregnancy, but they will do so at a slower rate than in a normal pregnancy. hCG levels may also decrease over time in an ectopic pregnancy.
c. Normal progesterone levels, decreased hCG levels
Incorrect: Though it is correct that hCG levels may be decreased in an ectopic pregnancy, progesterone levels would also be decreased.
d. Decreased progesterone levels
Correct: Decreased progesterone levels are indicative of a non-viable pregnancy, regardless of location.

3. Which of the following diagnostic tools can most accurately identify an ectopic pregnancy?
a. Transvaginal ultrasound
Incorrect: Transvaginal ultrasounds are inconclusive in up to 18% of women.
b. Serum beta-hCG
Incorrect: beta-hCG levels may still rise as normal in an ectopic pregnancy as a result of heterotopic pregnancy.
c. Diagnostic laparoscopy surgery
Correct: Laparoscopic surgery is the only way to actually visualize the ectopic pregnancy, and is therefore the most accurate method of diagnosis.
d. Dilation and curettage
Incorrect: The absence of chorionic villi in a tissue sample from the uterus only confirms that there is no pregnancy growing in utero, it cannot confirm an ectopic pregnancy.

Quiz 3
Quiz 2
1. With respect to treatments, which of the following statements is true?
a. Laparotomy is preferred over laparoscopy
Incorrect: Laparoscopy is prefered over laparotomy as it is less invasive, has lower analgesic requirements, less blood loss, and results in a shorter length of stay in hospital.
b. Salpingostomy is associated with fewer repeat ectopic pregnancies
Incorrect: Salpingostomy is associated with greater rates of repeat ectopic pregnancy, as some embryonic tissue may still persist after surgery. This is known as persistent trophoblast.
c. Surgical intervention is rarely used in conjunction with Methotrexate administration
Incorrect: Surgical intervention is very frequently used in conjunction with methotrexate administration to ensure that the ectopic pregnancy has been fully terminated.
d. Effectiveness of methotrexate treatment is monitored by hCG levels
Correct: hCG levels are monitored after treatment with methotrexate in order to ensure that the ectopic pregnancy has been fully terminated. If hCG levels do not decrease as expected, another dose of methotrexate may be given.

2. Which of the following complications does not result from surgical treatment?
a. Abundant hemoperitoneum
Incorrect: Abundant hemoperitoneum may occur during surgical intervention as blood is being lost from the vessels which have been invaded by the ectopic pregnancy. This can also occur due to damage of surrounding vessels during surgery.
b. Tubal rupture
Correct: Tubal rupture is a complication of the presence of the ectopic pregnancy in the fallopian tube causing distention, wall thinning, and subsequent rupture. This would not occur as a result of surgical treatment.
c. Hemodynamic failure
Incorrect: If hemostasis cannot be maintained during surgical intervention, hemodynamic failure can occur.
d. Persistent trophoblast
Incorrect: If some residual embryonic or extraembryonic tissue are left behind during surgical intervention, this can lead to persistent trophoblast.

3. Sarah can expect the following outcomes after resolution of her ectopic pregnancy
a. Infertility
Incorrect: Sarah had a salpingostomy, which means that the fallopian tube was left functionally intact. Therefore, she will still be able to become pregnant again in the future.
b. Increased risk for future ectopic pregnancies
Correct: Sarah’s ectopic pregnancy and salpingostomy have likely left some scarring in her fallopian tube, thereby increasing her risk for future ectopic pregnancies.
c. Early menopause
Incorrect: Ectopic pregnancy is not related to the onset of early menopause.
d. Lithopedion
Incorrect: Sarah’s ectopic pregnancy was surgically removed, so there is no embryonic tissue present to calcify into a lithopedion. However, if her ectopic pregnancy continued to grow undetected, this complication could occur.
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