Term
| what is an ectopic pregnancy? |
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Definition
| extrauterine implantation of an embryo - the leading cause of life threatening morbidity in the 1st trimester |
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Term
| where do the egg and sperm meet? |
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Definition
| in ampulla of the fallopian tube |
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Term
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Definition
| removal of the entire fallopian tube, was was done the first time in 1884 by dr. tait |
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Term
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Definition
| an incision made in the fallopian tube to remove an ectopic pregnancy, as was done for the first time in 1953 by dr. stromme |
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Term
| when was the first laparoscopic salpingectomy (tube healed on its own) performed? |
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Definition
| 1973 by dr.s shapiro and adller |
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Term
| when was the first laparoscopic salpingotomy (sewed back together) performed? |
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Definition
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Term
| what is the pathogenesis of ectopic pregnancy? |
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Definition
| any event that impairs the ability of tubal transport will predispose ectopic pregnancy, which occurs when proliferating trophoblasts invade the tubal wall. this proliferation of cells extends from the luminal mucosa into the muscularis and lamina propria into the serosa and ultimately into large blood vessels of the broad ligament, (doesn't grow into the tube, grows out of the tube). bleeding ensues as the tube is distorted and the serosa stretches - causing pain. 80% of the time the embryo is abnormal and regresses and 50% of the time spontaneous tubal abortion and the ectopic pregnancy may be clinically silent. tubal rupture is associated with significant hemorrhage (and possibly death). |
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Term
| what is the most common site of ectopic pregnancy? (*exam question*) |
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Definition
| the *ampulla of the fallopian tube* = site of 79.6% of ectopic pregnancies, because this is where the egg and sperm first meet. the next most common: isthmus then fimbria. rare: abdomen, ovary, and cervix. |
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Term
| what is the recurrence rate of ectopic pregnancy? |
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Definition
| 15% after the 1st and 25% after the 2nd |
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Term
| what are the risk factors for ectopic pregnancy? |
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Definition
| *high risk: tubal sx, tubal ligation, previous ectopic, in utero exposure to DES, use of IUD, tubal pathology, assisted reproduction (ART), and the morning after pill. *moderate risk: infertility, previous genital infections (ascending gonorrhea/chlamydia), multiple sexual partners, and salpingitis isthmica nodosa (inflammation of the tube itself). *low risk: previous pelvic infection, cigarette smoking, vaginal douching, and first intercourse @ <18 yrs. |
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Term
| what is the classic triad associated with ectopic pregnancy? |
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Definition
| amenorrhea, irregular vaginal bleeding, and lower abdominal pain |
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Term
| what is the most common complaint of women w/ectopic pregnancy? |
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Definition
| sudden severe lower abdominal pain - 90-100% of pts |
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Term
| what can happen if rupture occurs w/ectopic pregnancy? |
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Definition
| pain can radiate to the shoulder (b/c blood irritates the diaphragm), syncope and shock (from low blood volume) |
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Term
| what are the signs and symptoms of ectopic pregnancy? |
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Definition
| abdominal tenderness (90%), rebound (70%), and a tender adnexal mass in 50% of pts w/ectopic pregnancy. pelvic exam is usually non-specific. |
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Term
| what should be in the ddx for ectopic pregnancy? |
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Definition
| appendicitis, threatened abortion, ruptured ovarian cyst, PID (rare), salpingitis, endometritis, nephrolithiasis, ovarian torsion, and intrauterine pregnancy. alt dx/things you have to worry about: dysmenorrhea, dysfunctional uterine bleed, UTI, diverticulitis, and mesenteric lymphadenitis |
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Term
| whats the first thing you should do in every situation? |
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Definition
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Term
| how early can ectopic pregnancy occur? |
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Definition
| as early as 4.5 weeks gestation |
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Term
| what are routine dx tests for ectopic pregnancy? |
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Definition
| serial measurements of beta hCG (in normal pregnancy, beta hCG should rise at least 66% and up to 2x every 48 hrs), ultrasonography (presence of any non-cystic, extra-ovarian, adnexal mass in the absence of an intrauterine pregnancy is diagnostic of an ectopic pregnancy) |
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Term
| what characterizes abdominal ectopic pregnancy? |
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Definition
| risk of dying is 7.7x higher than other ectopics (due to high level of blood supply) and can be either primary: primary peritoneal implantation or secondary: aborted fallopian ectopic w/direct extension. *when diagnosed - sx is tx |
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Term
| what characterizes cervical ectopic pregnancy? |
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Definition
| most common predisposing factor: D&C. most common symptom: painless vaginal bleeding. |
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Term
| what is a heterotopic pregnancy? |
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Definition
| when a pt has one pregnancy in the uterus and one outside the tubes/uterus? it is rare and if seen likely related to the pt using ART. |
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Term
| what are the 2 treatment pathways for ectopic pregnancy? |
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Definition
| medical or surgical - depends on the stage of the disease and the condition of the pt @ dx. |
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Term
| what does medical treatment of ectopic pregnancy consist of? |
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Definition
| methotrexate (MTX), a folic acid antagonist which inhibits denovo synthesis of purines and pyrimidines - thus interfering w/DNA synthesis which trophoblasts are very vulnerable to. |
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Term
| what characterizes pts who MTX is appropriate for? |
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Definition
| pts need to be hemodynamically stable, the ectopic must be unruptured, the sac size has to be < 4 cm, and their beta hCH has to be less than or equal to 10,000 mIU/mL |
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Term
| how is MTX tx for ectopic pregnancy carried out? |
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Definition
| day 1: check beta hCG, CBC, LFTs (b/c of liver toxicity/possible leukocytosis). day 4: check beta hCG. day 7: recheck day 1 labs (make sure nothing is abnormal). from day 4 to 7, there should be a 15% drop in beta hCG - if not a re-dose is necessary. sx if pain lasting longer than 12 hrs occurs or falling hematocrit, orthostatic hypotension, or acute abdomen (signs of rupture) |
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Term
| what are the side effects of MTX? |
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Definition
| bone marrow suppression, hepatoxicity (most common), gastritis, stomatitis, pulmonary fibrosis, alopecia, and photosensitivity |
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Term
| what characterizes sx as tx for ectopic pregnancy? |
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Definition
| sx is the definitive therapy and can be laparoscopic surgery or laparotomy (if pt hemodynamically unstable or with acute abdomen go right to to laparotomy). the procedure can then be either a salpingectomy, salpingostomy, or salpingotomy. |
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Term
| what is the difference between salpingostomy and salpingotomy? |
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Definition
| salpingotomy is essentially the same procedure as salpingostomy except that the incision is closed with 7-0 vicryl or similar suture |
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Term
| how is a salpingectomy, salpingostomy, or salpingotomy decided on? |
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Definition
| all tubal pregnancies can be treated by partial or total salpingectomy. salpingostomy/salpingotomy is only indicated when: the pt has the desire to conserve her fertility, the pt is hemodynamically stable, tubal pregnancy is accessible, the tube is unruptured and <5 cm in size and the contralateral tube is absent or damaged. *there is a fertility scoring algorithm available for this (conservative sx is to remove the tube the radical sx is to leave that tube - based on risk of recurrence). |
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Term
| what are the only arteries which bring blood back in the direction towards the heart? |
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Definition
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Term
| what is a major concern w/performing a salpingectomy? |
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Definition
| ensuring the mesosalpinx is cut - so the ovary stays. |
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Term
| what is persistent ectopic pregnancy? tx? |
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Definition
| a complication of salpingotomy/salpingostomy when residual tissue is left behind - do serial hCGs to make sure their beta hCG returns to zero (if it does not return to 0 and it is untreated, it could be life threatening and have hemorrhaging). tx: salpingectomy or MTX (if they are stable) |
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Term
| salpingectomy vs. salpingostomy? |
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Definition
| salpingostomy has a higher subsequent intrauterine pregnancy rate - but the recurrent ectopic rate is higher |
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Term
| laparoscopy vs. laparotomy ? |
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Definition
| in a stable pt, laparoscopic salpingostomy is tx of choice (less blood loss, decreased need for analgesia, improved post operative recovery). |
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