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Test 3: Ectopic pregnancy (part 1)
Terms in this set (109)
what is an ectopic pregnancy?
A pregnancy that has implanted in a location other than within the endometrial cavity
_____% of pregnancies are ectopic
ectopic pregnancy is a significant cause of _________ in women of child bearing age
in countries or areas of the world where there is ________-prenatal care, ectopic pregnancy is the significant cause of morbidity and death in women of childbearing years.
Mortality rate has decreased due to what factors?
•Earlier imaging and diagnosis
•Sensitive hCG tests
why does ectopic pregnany occur?
Could be conditions that are interfering with the transport of the fertilized ovum to the endo cavity, or there are conditions that could predispose the ovum to implant prematurely before reaching endo cavity.
Normally the fallopian tube has ____________, __________ and _____________ to help with the fertilized ovum, sperm, and oocytes to move along from the tube into the endo.
tubal peristalsis, motion of the cilia, and flow tubal secretions
in the textbook it talks about a study they did for ectopic pregnancy, there was a theory that ectopic pregnancies were ____________different, that they had genetic abnormalities, but studies have shown there is no difference in the ________ makeup in ectopic pregnancies compared to normal intrauterine pregnancies.
up to _______% of pts that have ectopic pregnancy do not have any risk factors but there are some that we know increase the chance.
____________ abnormalities are the most common predisposing risk factor for ectopics.
....these tubal abnormalities include??
tubal scarring, from episodes from pelvic inflammatory disease, or salpingitis, if the pt had tubal reconstructive surgery, or if the pt has had a tubal sterilization procedure.
what is salpingitis isthmica nodosa?
nodular thickening of the isthmic portion of the fallopian tube and creates nodules and diverticula in the fallopian tube.
In more than 50% of cases of ectopic preg treated with surgery,__________________ is found because this is an increasing risk factor.
salpingitis isthmica nodosa
we also have pts who were exposed to _____________ in the uterus and it affects the formation of the _____________ and ______________.
-endo cavity and fallopian tube.
having a ________ ectopic pregnancy is also a risk factor for having.....
-more in the future
if you've had a single ectopic the risk of reoccurrence is ______-____%, if you've had 2 the risk goes to ______%
women who are going through __________ __________ _________especially ________ have an increased risk for ectopics.
-assisted reproduction therapy
.....this is thought to be because of what?
retrograde migration of an embryo that is transferred into the endo they think it is placed into the endo and go backwards into the fallopian tube and turn into an ectopic.
it is estimated that 25-50% of pts that have an ________ and become pregnancy develop an ectopic. Having IUD use in the past is a small risk factor
they think that _________ is a risk factor.
__________ ___________ at the time of conception is a risk factor, they think the________alters the tubal contractility and the motion of the cilia in the fallopian tube.
there are higher rates of ectopic and miscarriage in pts who have
-first sexual encounter before the age of 18
-or have their first pregnancy when they are older than 35.
clinical symptoms with ectopic appear ______-_______ weeks after LMP
What is the classic presenting triad (w/a positive preg test) w/pts with ectopics.
...the triad only presents in _____-______% of ectopic pregnancies because it is nonspecific and not a gold standard
a lot of women up to 90% have vaginal bleeding and pain whether it is a ________ pregnancy or not.
What are the signs of ectopic rupture?
•Loss of consciousness
•Shock from blood loss
pts who have an ectopic preg that is ruptured tend to be _____________ unstable, they will have all the signs on the previous card.
Rupture can occur at any ________without warning
nearly ________of ectopic preg do not have any signs or symptoms.
Some less common symptoms include
pts may also have
-cervical motion tenderness
-urge to defecate
why is shoulder pain recognized as a clinical sign?
they think it is referred pain from irritation of the peritoneal surface under the diaphragm due to hemorrhage within the peritoneal cavity
Why do pts present with the urge to defecate
because there is blood collecting in the cul de sac and there is pressure on their rectum.
What are the diagnostic test used for ectopics?
-human chorionic gonadotropin (hCG)
main lab value is hCG-hormone which is prod by the __________ of the pregnancy.
When is hCG first detectable?
first detectable in maternal serum 6-8 days post fertilization
usually, _______days after implantation or about the time the next expected period or four weeks after the last menstrual period-________% of urine preg test will be positive.
__________-________ mlU/mL is expected to be visualized of an IUP on TV
A ________analysis of hCG levels and follow up imaging are most accurate.
there will be a___________ or ___________ of hCG levels with ectopics compared to normal IUPs.
slow rise or fall
the rise of hCG will not _________over 48 hour time span
with ectopic hCG levels will not double but will _______
pts with _________ _________usually their hCG levels will go down, but with ectopic it will go down but will not be significant enough.
TV sonography is used in conjunction with ______
if serum hCG (blood)- is negative, ectopic is almost always ________
....they used to think if pt has less than ________ units in their blood... we would....
not see the preg on US
.....but now there is no set number especially between_________ or __________ and will need to test pt every _______-_______ hours.
in general, the hCG levels will be _______ in an ectopic than with an IUP of the same ___________ _________, still recommend TV even if lower.
approx ______% of women with ectopic preg,when they test serum hCG, there is a very slow rise or slow fall
before TV we need to do a brief what?
With TV sonography we need to assess for what?
-assess for FF
-fluid within the endo cavity
-scanning through pelvis
If the pt has a positive pregnancy test whether it is urine or blood, and we can't see a pregnancy on US at all they call this a ________.
PUL stands for
pregnancy of an unknown location
sonography alone is not reliable because ectopic may be what?
too small to visualize.
sometimes ectopic pregnancies can be in a ________ position so eval adnexa's and pelvic spaces
one of the biggest clinical signs of ectopic is__________ ____________ in the spaces or cul de sac.
if you have a pt and are sus of ectopic, you should evaluate what?
Morrison's pouch in the RT upper quadrant between the liver and right kidney to check for FF.
Make sure when using TV probe, the frequency is between _______-_______mHZ, we want to make sure we can see all around the UT, OVs, and adnexas, the textbook recommends setting depth so there is pelvic structures of the UT and there is _______-______ cm beyond the margin of that to eval around.
We are evaluating the cervix first; the walls of the cervix should be continuous with the __________into the body, so we can evaluate for possible cervical ectopic pregnancy or miscarriage, we should also evaluate the posterior cul de sac and look for ________ or __________.
-FF or hemiperitoneal.
Then we are going to evaluate the endo, myometrium, and adnexas very thoroughly, we need to see if there is any internal echoes, locate the shape and see if it is actually appearing like a ________ __________.
You will scan out pretty far __________, and we can use color or doppler sonography to evaluate for blood flow, sometimes there will be a ________________ appearance.
-ring a fire appearance.
where are the majority of ectopics located?
95% of ectopic pregnancies are located within the fallopian tube
why are the majority of ectopics in the ampulla?
it is the widest and longest portion of the fallopian tube
what are the percentages of ectopics in the other parts of the fallopian tube?
•Ampulla - 70%
•Isthmus - 12%
•Fimbriated end - 11%
•Interstitial - 2% - 4%
what are the unusual locations of ectopics?
Rudimentary horn would be on what type of UT?
the fallopian tube has a mucosal, muscle, and serosal layer, there is no _______ _________ that is there, like normally there is in the endo, so the ectopic invades the _________ layer of the fallopian tube and creates the trophoblastic tissue growing in the pregnancy.
.....this tissue grows and stretches out the fallopian tube and this is why it is so prone to __________ , the fallopian tube tissues are not created to maintain this growth of trophoblastic tissue.
if the ectopic preg adheres to tissue outside the fallopian tube it is difficult to separate it especially once we have a placental tissue start growing and these pts have a high chance of ____________.
What are the sonographic findings of the UT with an ectopic?
•Absence of an intrauterine gestational sac
•Fluid within endometrial canal
•No visible IUP
•Intradecidual sac sign for IUP
•Visualize yolk sac within endometrial fluid for IUP
What are the sonographic findings in the adnexa and CDS?
•Extrauterine gestational sac containing a yolk sac or embryo is diagnostic
•Adnexal tubal ring (50% of cases)
•Empty gestational sac with thick echogenic rim
•Variable Color Doppler findings
•Nonspecific adnexal mass
...the nonspecific adnexal mass with an ectopic can appear how?
the sonographic findings with ectopic in the UT, adnexa, and CDS are....
not very specific.
in the UT we will not see an intrauterine gest sac or fetal pole, but sometimes we will see __________in the endo canal, and this could be confused for an _________ ________ ________.
-early gestational sac
if there is no visible intrauterine gestational sac, we need to include the possibility of an ectopic, or failing pregnancy, or could be a very early pregnancy, at this point this preg is called a _________
if we do see an intrauterine preg, it makes the probability of an ectopic pregnancy very rare or unlikely but _________ pregnancies do occur.
____________ ___________is not shown to be a reliable predictor of ectopic pregnancy.
....sometimes endo will thicken up as a response to________ ______ but there won't be a gestational sac in there.
But if we do see an intrauterine gestational sac and it has a yolk sac or a fetal pole in it that is much more definitive that it is an actual pregnancy instead of ______________
They used to use the term _________gestational sac so sometimes if we had fluid buildup in the endo it would appear with....
-low level echoes it could have blood or secretions.
the most specific finding of an ectopic is an _____________ gestational sac containing a yolk sac or embryo, the fetal pole may or may not have what? this is 100% positive of an ectopic preg.
....Sometimes we do not see a fetal pole or yolk sac all we see is an adnexal __________ _________ that is an empty gestational sac.
This adnexal tubal ring will appear how?
round anechoic fluid collection, thick echogenic rim, called a BAGEL OR DONUT SIGN.
The tubal ring in this adnexal mass will be clearly separated from the ________, if it is already ruptured into the tube, could look very nonspecific.
usually, ectopic preg will be anywhere between the_________ and the ________ or in the __________but could be in a really high spot or anywhere around the _________.
-ovary and the UT
with an ectopic you'll see vascularity, ring of fire, could look like a __________ ___________.
...if the ectopic has already ruptured there will be FF with internal echoes, complex material, indicative of_________ _________ , they do say the amount of FF is an indicator of how.......
- stable the pt is hemodynamically.
If all the cul de sac or pelvic spaces are full of complex FF...what happens with the pt and what do we need to assess for?
this pt will go into shock, she is losing a lot of blood we need to assess the upper abdominal spaces.
If we have a pt that has some of these symptoms or maybe has FF, but we don't see an ectopic pregnancy or intrauterine pregnancy, they will have to do follow up with __________ and _____________ to watch pt very closely, because we do not want the pt to go into shock from________ _________.
-hCG and TV sonography
What are the pitfalls in imaging for ectopics?
•Lack of operator experience
•Blood flow in tubal ring of an ectopic is more likely to be focal and segmental
one of the biggest pitfalls is?
lack of operator experience
-make sure you are taking a complete and thorough pt history: see if they have any risk factors like what?
prior ectopic pregnancy, reproductive therapy, previous tubal surgery, or previous PID.
another big issue is differentiating_______ ________ from ectopic pregnancy.
a corpus luteum is a cyst that will arise from the __________, _____________ectopic pregnancies are extremely RARE.
if you have a corpus luteum you'll see it on or within the ovary, you'll see ovarian _____________around this.
if it is mass that is adjacent or separate from the ovary this will be an ectopic preg, there will be no what?
ovarian tissue around it.
what can we do to separate the ectopic pregnancy from the ovary so we can differentiate it?
we can move with the TV transducer or palpate on the pt anterior abdominal wall
what are the treatment options or management options for ectopic pregnancies?
-criteria for methotrexate
which treatment is the current standard?
lapraroscopy is the current standard surgical approach
what are some pros of laparoscopy
•Lower incidence of postoperative adhesions
•Less blood loss
the last resort
they only do a hysterectomy most often in the setting of what?
what is the criteria for methotrexate?
•Hemodynamically stable (no signs of active bleeding)
•Maximum diameter of ectopic 3.5 - 5 cm
•NO embryonic cardiac activity
•Serum hCG level lower than 10,000 - 15,000 mIU/mL
what does the chosen treatment will depend on?
-location and imaging findings
-if there is cardiac activity
-if the pt is showing signs of hemodynamic instability and a lot of complex FF that could be blood products.
they usually try to do a laparotomy or salpingectomy because why?
to preserve the fertility.
methotrexate is pretty successful in treating ectopics, but pt has to be hemodynamically stable and have no signs of _________ __________.
they have tried direct injections of__________ or _________ into the ectopic sacs as treatments
methotrexate or potassium chloride
these injections would be more specific for what?
more specific for more unusual ectopics such as C section scar, cervical, or interstitial ectopics
...why is this more specific for unusual ectopics?
because these pts have a higher chance of hemorrhage.
Sets found in the same folder
Test 3: The obstetrics ultrasound examination
Test 3: EPs Unusual places for ectopics (part 2)
Test 3: US of the early first trimester
Test 3: Eval of fetal anat in 1st Tri (pt 1)
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