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Don't lose me. I won't. Good morning, everyone. Well, or afternoon or evening, wherever you're joining us from, for me, it's half past nine on a Friday morning. Um, it's lovely to have you join us. We have, er, David Kell joining us again today. He's gonna talk about ectopic pregnancies. You can catch his previous talk on miscarriage on our platform that's on demand now. And his next talk is on a, that's the one I didn't know if it's a hahp or a ph I couldn't quite. But yes, his next talk is next week and the link is in the chat after the event. As always, we'll send you a feedback form once completed, you will get your, er, certificate on your medal account. We would love for you all to, you know, input your feedback. David was really keen to get feedback and, er, if there's any questions that he hasn't been able to answer, you can pop them in too and you might be able to get them the following week. But, um, yes, we're really keen to get your feedback. If you could pop your questions in the chat, that would be greatly appreciated. David will talk for about 45 minutes and then we'll have about 15 minutes of Q and A right at the end. So please pop your questions in the chat. So that's over to you now, David. OK, thanks very much, Sue. So, so just mentioned about feedback and I guess feedback can sound like a very boring thing to have to do. But in some senses, it's important for you as the listener to show that you've maybe learned something from the experience. It's also important to me as the deliverer that I am hitting the button for you in the right place that I'm getting whatever it is that you, that you're getting, whatever it is that you want me to talk about and, and that maybe I need to learn. And so I, I'm willing and ready to learn from whatever comments you make. So last week we spoke about miscarriage. Uh this week we're going to talk about ectopic pregnancy. These topics are slightly related in the sense that they are both to do with the early part of pregnancy, generally speaking the 1st 12 weeks or so of pregnancy. And I wanted to talk about this um to you this morning while I was asked to talk about it. And so what I'm going to be doing is trying to cover these learning objectives for you thinking about um how to make a diagnosis in somebody who presents with symptoms that might be related to ectopic pregnancy, thinking about appropriate uh decision making for treatment and recognizing that um some of you will be in hospitals with a lot of diagnostic equipment, with a lot of therapeutic opportunities and some of you won't. And I, I've worked in places where the amount of um diagnostic equipment was quite limited and the therapeutic uh abilities were limited. And so you have to what you need, what you as an individual need to do with this is to take from it, what fits your own individual situation? Excuse me. Uh I will want to cover uh how you relate to other disciplines in medicine with regard to this. I want to talk a little bit about how you manage uh the patient after you've treated the situation. Um and we'll deal with that and then finally, some issues to deal with with regard to counseling the patient. Um And like last week where I had some questions to test you on your knowledge and how well you've been listening, we'll have some questions again on, on this topic specifically at the end of this section. So off we go. Um so the diagnosis of um ectopic pregnancy is related to the symptoms, the physical signs, the appropriate use of blood tests for human chorionic gonadotropin, mostly thankfully shorter to HCG and the appropriate use of ultrasound, preferably transvaginal ultrasound because it's much more because the accuracy and the reliability of the ultrasound is much greater if it's transvaginal rather than transabdominal. And then finally, as you move from diagnosis on to treatment, the use of uh laparoscopy if you've got that available to you or laparotomy, if you don't have laparoscopy available to you, I think one of the things to be aware of uh and this sounds a bit, um maybe it sounds a bit like um a very anti woman statement. But when you're considering a woman presenting to you with odd symptoms or signs, if you don't consider that every woman could be pregnant until proven otherwise, then you will miss uh obvious things like ectopic pregnancy. If you don't think pregnancy and complications of pregnancy, then you will perhaps miss this. This is relevant, not just for ectopic pregnancy, it's also relevant for things like appendicitis in which situation. Uh as you advance in pregnancy, the site of pain moves from the lower quadrant on the right hand side, maybe to the middle of the abdomen because of the changing site of the appendix with the advancing pregnancy. So it's just being aware of that as an entity that you people should be considered pregnant until proven otherwise. So when we think about atopic pregnancy, actually, it's been, it's, it's great and it's quite a feat that maybe, well, I put down here 15 years. So this is 2023. So if you think back to 2005, that's actually almost 20 years. Um the way that we've been dealing with the management of opic pregnancies and how they've been diagnosed has changed radically over that time, it's changed because um, testing for HCG has become much more precise and we, it's become more dependable and more rapid and the ability to use ultrasound has um mushroomed in terms of its breath. So nowadays, many junior doctors will have been exposed to ultrasound. And of course, one of the challenges with that is that they may have been exposed to it, but they may not be properly trained in it. And therefore they may think they know what they're doing but might not do so. So when we're thinking about the um the symptoms and the signs, we'll come to those in a moment. But the management of ectopic pregnancy would be best done within an area of the hospital that was focused on symptoms and signs in early pregnancy. This relates also to miscarriage uh because that's a condition which would be ideally manageable in that same setting where the focus really is about um sifting out the women who have got maybe nothing wrong with them and who are not pregnant, but who think they are the women who have got a healthy ongoing pregnancy in their uterus and will be fine. And then the women in the middle who will have pain and bleeding and our job, your job as doctors is to sift those out and pull them apart and figure out where does this person fall? Uh and so ultrasound and biochemistry using HCG become really important. Now, this is a complex slide which um I'm going to go through only in a little bit of detail. It will be in the handout that sue will have for you available at the end of this lecture. But what I've tried to do here on this is to pull together um the evidence, the data that we've got from several different uh research papers published about the size of a pregnancy at different gestational ages and correlate that with the amount of HTG hormone that might be being produced. So on the left hand side, if you look down, it says four weeks, five weeks, 5.5 weeks, six weeks, 6.5 weeks, seven. So this is the time when many women will be presenting with a bit of bleeding or a bit of pain. And we need to try to use this sort of information to help us. The, the the information on this slide is only useful if you have got good skills in ultrasound and only useful if you've got a laboratory that uses uh up to date uh testing measures for human chorionic gonadotropin. But what you can see uh from it is there are a number of changes in the lining of the uterus, the endometrium, the size of the gestational sac, the presence or absence of that thing called the yolk sac. Then the crown rump length of the fetus. And then finally, the expectation of the time when you might see a fetal heart. And on the far right hand side, you can see the expected amounts of HCG for different times of pregnancy in a normal healthy, ongoing pregnancy. So, in a nutshell, what you can see is that the endometrial thickness increases over time, the gestational sac increases the yolk sac, which is a tiny structure within the gestational sac increases. And that's useful particularly if you're, if you see somebody and they don't know how pregnant they are and you see a gestational sac and there's a tiny yolk sac measuring two millimeters in size, then you know that they're not going to be seven weeks pregnant. Even if you can't see a fetus, um the fetus should be visible, the crown do blank should be measurable at 5.5 weeks. You would not expect to see a fetal heart at 5.5 weeks. You might see a fetal heart at six weeks and you can see that the levels of HCG between five weeks, six weeks and seven weeks increases enormously. Um if a healthy pregnancy is there. So when we think about uh the blood results, uh sorry, when we think about the blood results, we're thinking particularly about the HCG and here are some um uh made up results but to show different types of pregnancy and what's happening with them. So on the left hand side, on the left, on the axis, on the left hand side, you see the rising levels of HCG and on the X axis on the bottom, you see blood tests done on Monday, Wednesday, Friday, Monday. Um And what you can see here is that everybody starts uh on Monday at maybe uh 45 weeks, gestation with a bit of pain and maybe some bleeding. And by the time you get to the following week, you then know using their HCG levels only, either their pregnancy is healthy and ongoing and the HCG levels are rising appropriately or they're not rising appropriately. Now, that does not tell you what the diagnosis is. It tells you the pregnancy is not doing well. So it could be an intrauterine pregnancy that's dying and failing. It could be an extrauterine pregnancy that's still alive and healthy and potentially going to cause health problems. And you don't know and you have to use other methods to determine which of those two is falling into. So, if the woman's perfectly healthy and well, um and has lost some pregnancy symptoms, perhaps her breasts are no longer tingling and she's no longer getting up at the night to go to the toilet. Maybe that's a failing intrauterine pregnancy. On the other hand, if she's got grumbling left sided, lower abdominal pain, um and feels sick and feels pregnant, maybe that's an ectopic pregnancy, but this alone does not tell you that. So here are some risk factors associated with ectopic pregnancy. So there's an age issue. So what the most likely age is going to be between 25 and 35 essentially people younger than that will have ectopic pregnancies, people older than that will have it. But this is the biggest risk age, people who have had trouble in trying to get pregnant have a much greater risk of infertility. People who previously had a sexually transmitted disease, especially with chlamydia trachomatis are more likely to have an ectopic pregnancy. And there is a blood test available to try to judge how much chlamydia infection somebody's had in the past. And that gives rise to an antibody result in the woman's antibody levels in her body. And consequently, if you measure the that blood test for chlamydia antibodies, and you find that there's lots of antibody present, then she's also much more at risk because she's had previous infection, which you might not be aware of somebody who has had a sterilization operation done in the past. Uh And particularly if they've tried to have it done uh and then reversed as it were. So they decided they wanted more Children, then their tube was going to be, their fallopian tube was going to be damaged. And the consequences of that are that she's again more likely to be at risk of ectopic pregnancy. She may have an in uterine contraceptive device in place. Now, that itself is not a risk factor for ectopic pregnancy. But if somebody gets pregnant with an an intrauterine contraceptive device, they're much more likely to be pregnant outside their uterus than if they didn't have one. So that, that just takes a bit of getting your head around. So women with an IUD as it's shortened term are not more at risk of an ectopic pregnancy. But if they do get pregnant, their pregnancy is more likely to be outside the uterus because the because the contraceptive device stops intrauterine pregnancies, it doesn't stop extrauterine ones. So if she is pregnant, she's more likely to have an ectopic pregnancy. And endometriosis is down at the bottom of the list as a a factor which may give rise to tubal uh motility and mobility problems because of the damaging effect of endometriosis. And therefore somebody with that condition might also be slightly more at risk. So the test that we use, how precise are these tests? This is really important. I think so in uh there's a study, uh the public details are down at the bottom and in two different papers. Uh and once one hospital uh in South Korea looked at this and they studied 20,000 deliveries or more uh in their uh 13 years of of clinical practice. And what they found uh in that time span was that of the 20,000 deliveries, there were 1000 ectopic pregnancies. And one third of those women presented without the ectopic pregnancy being ruptured, two thirds presented with ruptured ectopic pregnancies. Therefore, leading to bleeding, the need for surgery being much more acute, much more serious and the potential for life loss being much more evident. So that gives you an incidence from their study of about 5% of pregnancies ending up as ectopic pregnancies. The other study that is quoted looked at the effectiveness of the test that you can see on the other side at diagnosing ectopic pregnancy. So, ultrasound again, vaginal ultrasound, HCG and that beta, that funny symbol in front of the HCG is the, the sorry, the Greek letter beta, which denotes a specific half of the HCG molecule which is only found in uh HCG in pregnancy. The reason for being fussy about it is that other hormones like FSH and LH and TSH H all and HCG all share the common bit, the alpha bit of the of the protein chain. Therefore, you, you can get confused by doing that. And indeed, LH, the hormone and HCG are almost identical in their structures apart from some bits of the beto chain being different. Uh So laparoscopy is a test you can use to diagnose it, urinary pregnancy tests uh can be used and then the bottom one which has a long name of col do centesis. What that means effectively is that you, you, you examine the woman, you put a syringe and a needle up through the top of the vagina and if you withdraw back on the needle and you find blood in the peritoneal cavity, then the likelihood is she has an ectopic pregnancy. So the accuracy of these tests and their effectiveness in being both accurate and correct and uh being sure that the diagnosis is the right one ultrasound is by is very good HCG levels are very good. The combination of those means that they are almost by doing the two of them, you're, you're almost 100% but not quite effective in the result. Laparoscopy is not so effective as a diagnostic test. It's good for treatment, but it's not so effective with the diagnostic test because you can, you may not be able to see the ends of the tube and the full tube itself. Urinary pregnancy tests are practically useless at diagnosing pregnancy and culdocentesis is uh not much better laparoscopy uh is 90% effective, but of course, it needs a general anesthesia and the skills to do the laparoscopy. So you may sometimes end up doing it because you don't know what's going on and, and you to proceed, but you have to be able to do it and it requires an anesthetic and surgery. And there are some risks associated with that, which there are not with HCG and US and ultrasound. So, a woman presents with symptoms and your job is to figure out what's going on. The list. Here is some of the options that might be wrong with her if she presents with a bit of pain or a bit of bleeding in the first half, 1st 3rd of pregnancy. Um So they might be related to the pregnancy. So she might be having a miscarriage in any of its many forms. She might have an ectopic pregnancy. She might have that condition called Hida deform mole. Um And she might have a, what's called a cervical ectropion. Uh and may have some bleeding from that often after intercourse. A cervical ectropion is not a pathology. There's nothing wrong with somebody who has that. And it comes about because in pregnancy, the estrogen that's being produced in vast amounts makes the lining of the cervix grow and the lining in the cervical canal grows more than the lining on the outside of the cervix. And so it inevitably pushes out onto the surface of the cervix that you might see when you do a spectrum examination. And that is all that is then is a cervical ectropion. That's all that means, but it's friable, it's likely to damage. And if you touch with the speculum, it will bleed and having intercourse will sometimes make you bleed. So the symptoms might be related, might be coincidental to the pregnancy. Um So she might have, she might get pain because the supporting corpus luteum providing progesterone to the ongoing pregnancy might suddenly burst or twist and have an ovarian cyst accident. So both those things are possible and would cause pain. She might have a fibroid, uh which was on the surface of her uh uterus and that might twist and then that would cause a lot of pain. She might have a cervical malignancy and that would cause pain. And we'll deal with that in a bit more detail next week, thinking about the causes of antepartum hemorrhage. But if a woman presents on several occasions in pregnancy with vaginal bleeding, and if it's not due to miscarriage, and if it's not due to uh ectopic pregnancy, and if it's not due to any of the more pregnancy related causes of antepartum hemorrhage, you must consider a cervical cancer and you must do a spectrum examination. Uh I remember I worked in one hospital in Dublin a long time ago now, but every year we had about 10,000 deliveries. And so in this hospital where there were 10,000 women delivering in, in one year alone, I came across two women who came into the hospital with bleeding in pregnancy and both those women had cervical cancers. So this is not, this is not just a rarity that you'll never see. But if you're in an active busy hospital, you will probably see it at least once every two or three years, if not every year. And then there are things that are not related to the pregnancy and that are not due to anything in the pelvis. So, um appendicitis is a cause of pain renal colic is a cause of pain, interstim obstruction, cholecystitis, all of those things. So it's important to be aware of the wide range of possibilities and not just to focus on one thing, obviously, and the investigations you do might help you to work that out. So, really with all of this and with all of the tests and that you're going to do, you're going to arrive at a range of diagnoses. So the woman will either have an unruptured ectopic pregnancy. In which case, it might be in her fallopian tube. It's most likely going to be in her fallopian tube, uh where it's likely to be or it might not be. In which case, it makes it much more difficult to find. She might have a ruptured ectopic pregnancy. And then again, that's most likely to be in the fallopian tube and then she could have what's called a pregnancy of unknown location. In other words, you have no idea where it is and you can't find it. That's very rare. But bear in mind that the uh fertilized egg embryo and, and implanting embryo can dig in anywhere. So it can, it can dig in an implant into the fallopian tube to give an opic pregnancy. It can, if it's lucky, give a pregnancy in the uterus and that's an ongoing healthy pregnancy, hopefully, but it can go other odd places and uh odd places in particular will be the peritoneal lining uh in the pelvis or the omentum. Both of which places, particularly the omentum has got a relatively good blood supply uh to foster and allow to grow a pregnancy developing there. So you may find yourself with all of the tests pointing towards an atopic pregnancy. There's nothing in her uterus so that it's definitely outside the uterus. You can see the, you can see the fallopian tubes if you're really good at ultrasound and it doesn't look like there's anything there. But the tests are all saying that there is and that's a very difficult thing to manage then. So for the first one of these, uh the unruptured pregnancy in the fallopian tube, probably conservative methods are worth considering there. So you don't operate and you do things without intervening with the unruptured one, probably not in the tube. Again. Uh You would certainly want to think about conservative methods, um, medicines that will stop the pregnancy developing and allow you to deal with it in a safe way if it's ruptured. Almost certainly, you're going to need to think about doing surgical methods and finally, with the pregnancy, that's a unknown location. Again, in that situation, conservative methods are probably going to be the best. So what do I mean by that? Um So in many hospitals now you will manage a pregnancy that's in the wrong place by using drugs to effectively stop the pregnancy growing and methotrexate, which you, you may from your training. Remember as being an anti cancer drug and also as an anti rheumatic uh anti rheumatoid arthritis drug is quite effective in this situation. The reason is that it antagonizes folic acid and folic acid is a critical um enzyme in the development of a a new pregnancy. And if you give somebody methotrexate, it causes that uh enzyme pathway to fail and then the pregnancy will hopefully fail. It's a fairly simple drug to give and you give patients one mg of it per kilogram of their body weight with a minimum of 50 micrograms. Sorry milligrams of micrograms, 50 mg. And you can see from the numbers there that about at least three quarters of women will find this to be effective in treating the ectopic pregnancy. Um The danger here or the big challenge here is that these conservative methods don't remove the ectopic and there's still a risk of rupture of the ectopic until the pregnancy levels fall away to nothing that could take two or three weeks easily. So that does mean that the woman cannot, if you give a woman methotrexate uh for her ectopic pregnancy, you should then be sure that she's not going to get on an airplane flight to go to China or South Africa or America because if it ruptures uh she's at significant risk and actually it doesn't really matter where she's flying to. But the point is that you shouldn't, she should actually be close to the hospital because you will need to follow her up for a blood test for the next two weeks, probably at least. So, if she's not prepared to do that and not willing to do that, then this is not the treatment for her and maybe you need to think about surgical methods. So a reminder uh briefly of pelvic anatomy. So in the middle uh is the uterus and everything in this diagram is on the right hand side. Um I I admit that I stole this picture from a book called Clinical Anatomy by a guy called Harold Ellis, who was a professor of anatomy in London. And uh if you, it's the most useful anatomy textbook because it's all clinically orientated. So in this diagram, you can see the ovary with the line going to it, you can see the ovarian ligament holding the ovary in place. And most importantly, you can see the fallopian tube. Uh and there are several sections of the fallopian tube, the isthmus, which is the closest bit to the uterus and the narrowest bit of the tube, the ampulla, which is the a widening bit and then the infundibulum, which means I think it's a Latin word for hallway. And then the femoral end of the tube, that ampullary area in the tube is the usual site for ectopic pregnancies. And underneath the fallopian tube, there is an artery supplying it. And in that artery comes the blood supply of the ovarian artery and blood supply to the uterus and it supplies the fallopian tube and that, that will be very vascular in the situation of ectopic pregnancy. Um One of the things also to remember with this, this is a, this is a diagram I drew myself. So this is my cartoon drawing of a length of fallopian tube. The outside of it is in pink. There's a uh red, sorry, there's a black line uh which is the muscle around the fallopian tube. There's the orangey bit, which is the uh cellular area within that muscle. And then the white bit is the the passageway of the fallopian tube called the lumen. And when somebody has an atopic pregnancy, it's the pregnancy will almost always, well, certainly usually be embedded and implanted into that orange area. Um And uh therefore, you need to get at that if you're trying to remove it. So, coming on to thinking about how we manage ectopic pregnancies in terms of um removing the tube or conserving the tube. So if the, if the pregnancy, if the ectopic is ruptured, then clearly you have to remove the tube because it's bleeding and nothing else is going to stop the bleeding if the woman is. But if it's not ruptured and if her blood results or blood tests or, or hemodynamics are normal, her pulse is stable, her BP is stable. Her hemoglobin is 100 and 40 her HCG is relatively low, less than 10,000, you might think about just taking out the pregnancy and not taking out the tube. If the tube is damaged by scar tissue, then you should remove the tube. And of course, if she's had an atopic pregnancy before, then you should remove the tube because it's unlikely she's ever gone to a healthy pregnancy. So, this is my adaptation of the diagram that you saw earlier and I've drawn in here where I would see the ectopic pregnancy, I've drawn in the red blood vessel to show it much more clearly and the way you would manage. So this is the procedure of the approach to just removing the ectopic uh and not removing the tube. So this is the operation is called Salpingo toy. That means sal refers to fallopian tube and ostomy refers to cutting open. Um So the word gastrectomy means uh cut, removing the stomach. The word uh gastrotomy means putting a hole in the stomach. So this is the ectopic pregnancy on the fallopian tube. And then we, I would, if I was doing this, I would inject uh vasopressin, which is a uh as as it name suggests, it's a constrictor of blood vessels and that will stop the blood supply temporarily to the fallopian tube. And you inject that into where the blood vessels are to make them constrict. You then make an incision in the fallopian tube that's outlined here in purple. And then finally, you cut that open and you uh try to encourage the atopic pregnancy to get dissected out by squirting water or saline or some other fluid like uh uh heart to squeeze the ectopic pregnancy out by dissection. So you don't touch it, you don't make it push out you. But using the, the flow of water, you push it out in that way and then you leave it open afterwards, you remove the gestational tissue and you leave it open to heal by itself. You make sure that the the margins are not bleeding and you will allow it to heal then after that. So this is uh this is a diagram of the forceps in the fallopian tube about to remove the ectopic pregnancy. It's remarkably blood free. This was not me operating. So I can't boast about it. Uh But you can see that the operator has got no blood and the margins of the opening into the tube are all blood free. So he's been very he or she have been very careful about opening the fallopian tube and causing no blood loss and they're about to remove the ectopic pregnancy. So, which of these should you do, should you cut into the tube and remove the ectopic pregnancy or should you remove the tube completely? So, if you want a final job that's going to be effective and you can be sure that it's going to do the job, then removing the tube is um the safest most effective way of dealing with it. And whether you remove the tube or remove just the pregnancy by cutting into the tube, the ongoing likelihood of a woman getting pregnant subsequently is almost the same. So roughly 50% of them will have an in Children in pregnancy in the future. But if you cut into the tube, you do have a higher risk of pregnancy after that of ectopic pregnancy by three and 20 as opposed to two and 20 pregnancies. So on balance, most people would say that what you should do is to remove the tube completely because there's not a lot of benefit. Um But sometimes, you know, if, depending on the skill of the surgeon and the desires of the woman, you may want to argue it, but you can see that there's not a huge difference between them. Um in terms of collaborating with other workers. Clearly, this is a multitasking job here. You'll need to deal with the ultrasonographer to make sure the diagnosis of the ectopic pregnancy is accurate. You'll need to do with biochemistry staff to get your blood test results for the HCG. She may need blood if the pregnancy is ruptured. And what's fascinating to realize is how much blood somebody can lose in such a short space of time. So I will admit to you uh now that um 10 years ago or so I took a woman to theater in the middle of the night because she had the symptoms of an atopic pregnancy and I looked in with a laparoscope and could see the pregnancy was sitting there unruptured in the fallopian tube. And as I was getting ready to uh deal with it, the I touched the pregnancy and it ruptured and bled and within a minute, she had lost two liters of blood, two liters of the five liters of blood she had in her circulation. So these are very vascular and they can bleed really quickly. So you will probably need to work with the blood bank to have some blood on standby. Gynecology. Nurses will be essential in terms of the post operative care of the woman and the anesthetist and staff obviously also as well. Now, if you did a salpingectomy, then you've removed the pregnancy in its entirety. And therefore, there's no major POSTOP required apart from, you know, the normal checking of the abdomen to make sure there's no bleeding, no um uh in fact, no wound problemss or whatever, if you did not remove the ectopic pregnancy. So that might have been if you treated her medically with methotrexate or you treated her surgically uh with this, the cutting operation. The Salpingo toy, it's not enough to let it there. You've actually got to follow her up with HCG levels for days afterwards. So usually 10 to 14 days are required before you can see levels of HCG falling away. So I've just made a, a diagram here in yellow and blue to illustrate that what generally happens in these situations is that on the day of the operation, the blood result for HCG will be say 8000, 2 days later, it will be 9000. You're thinking, oh no, it hasn't worked. But actually it continues to produce HCG for a day or so after you've dealt with it with by medical treatment or even surgical treatment and only then does it start to fall and it will take another 10 days or so for it to fall back to levels of one or 200 international units of, of per mil of HCG. At which point, you can say it's now very unlikely to rupture and you can go home or you can stop being followed up. If on the other hand, the blood Dels don't fall, they rise to a peak, but then they kind of are much more slow in their fall after that like this uh line here. That's not, that's not good. That means that you haven't adequately dealt with the problem. Much more likely to happen with methotrexate than with Salpingostomy. And the probability is she's going to need to have more methotrexate. You need to be careful if that's the case that you don't cause her to run into problems with her production of her own blood because blood needs folic acid as well as the pregnancy. And therefore you want to check her hemoglobin and her uh indices of blood to make sure that she's not becoming anemic uh in the megalocyte blastic form that occurs with folic acid deficiency. And clearly, if it's not just not going down, but actually starts to go back up again, then you probably will need surgical intervention, not just medical, uh, but certainly you need to do something. You can't afford to let that continue. So, with regard to what you're going to tell patients, um, so this, this uh is a challenge. So if they've had a previous tubal surgery because of infertility or if it been infertile, then they have a much higher chance of a further ectopic pregnancy than if they were previously never had a pregnancy. If this is not their first ectopic pregnancy, they are again at a much greater risk if they've had previous surgery. And if there's adhesions around either tube and the sorts of questions I think they're going to ask are, well, what can I do? You know, what can I as the patient do? And will it happen again? And why has it happened? Now? Those are very sensible questions and I think we need to have, we need to have answers for those. Um And to help you deliver some of those answers, I think, I mean, what can I do? There's not a lot a woman can do apart from once she knows she's pregnant. If she has the opportunity to go to a place where ultrasound and HCG levels are measured then that will help because at least you'll have an early diagnosis. It won't stop her having an ectopic pregnancy if she's got it, that this will show she's had it earlier and you can therefore treat it more, uh, calmly than you would otherwise do, but it won't stop it. Will it happen again? We're going to deal with that one just now. And why has it happened? If this is her first time she got pregnant and if she's had no past history or no risk factors, then um it's really difficult to know. Some people would say that an ectopic pregnancy is related to uh implantation happening late because the ovulation maybe happened a bit late. The egg got fertilized and then in its journey down the fallopian tube towards the uterus, it gets to that stage where it's ready to implant and it does earlier than it should do as it were. So its journey is delayed and therefore it happens like that other people think that uh ectopic pregnancies are more likely to have some sort of chromosomal abnormality because they don't function as well normally and they may well implant later as a consequence of that. Will it happen again? So, if she's had the first pregnancy, uh and there was no other problem and it was managed well, then the likely and if it was managed expectantly, there's a very low risk of secondary couple of pregnancy. If it was managed medically, there's about a 10% chance. And if it was managed surgically again, close to 10% chance, those results are not significant. So you can tell the patient that if she's had one ectopic pregnancy, she's not really at risk of having another one and more than anybody else. On the other hand, if she's had two ectopic pregnancies, then with no matter what management you're using, there is a much greater chance. And if she's had expected management of the previous ones, then there's a 50% chance of her getting another ectopic pregnancy under 20 of if she's had medical and just over 10, if she's had surgical treatment in the past, and if those pregnancies that were managed conservatively were managed expectantly and they were both on the same side, then the chances increase for both expected management and medical management. So if it's her first pregnancy, her first ectopic pregnancy, her risks are no greater than they would be for anybody else. If she's had a second ectopic pregnancy and it was on the other side than it is. Now, then she does have an increased risk of a further ectopic pregnancy. And particularly if both pregnancies happened on the same side, really, if you have two pregnancies happening on the same side, you should be treating that surgically by removing the tube because that's the sensible thing to do. Now, we're going to just to, we're almost finished and I want you to consider, uh, Now, in your, in where you are, I'd like you to consider these questions. So, um there are three questions like there were last week and uh you can all read the key points. Here is the woman has had pain for maybe three days. Her last period was 25 days ago and was normal. Her vital signs are normal. Her hemoglobin is fine. Uh no evidence of anemia. Her crp her c reactive protein is 47 and her white cell count is 22. So, there are several diagnoses here, ectopic pregnancy, acute cholecystitis, diverticulitis, acute inflammatory disease of the pelvis and acute appendicitis. So in your chat, could you put in ABC or D or E as to which of these you think is her diagnosis? So, if you do that now? Ok. Moving on. Uh again, another woman, 34 vaginal bleeding, low abdominal pain, she felt faint about six hours ago and she's never been pregnant. Her last period was three weeks ago. Select from the list below the most appropriate bedside or near bedside investigation. You should take, you should do first for her ATG progesterone transvaginal scan, full blood count or BP, ABC RDRE. And then finally, a 28 year old woman, stable relationship on the pill presents because she hasn't had a withdrawal bleed, which of these clinical findings is most likely to lead to the diagnosis of an ectopic pregnancy. There are five clinical findings, pain, pain, hypertension bleeding and fainting and shoulder to pain. ABC DRE. Ok. I'm going to s to, uh, in my show and come back to you soon. Hopefully. Yes, I'm here. I quickly put a pull up whilst you're doing that. I didn't have the writing, but we did question one and we've got, I don't know if you can see the chat. So we've got a and D 80% said a for your question one and 20% said D OK. So let's stop there for a moment. Um Thank you for putting that Paul. That's a much more sensible way to maybe we can do it again next time. So, right. Ectopic pregnancy or PD, her hemoglobin is normal. Her vital signs are normal. Her c reactive protein is 47. Most of you listening in, hopefully your c reactive protein is under 20. So AC RP of 47 indicates generally some sort of infective or inflammatory process. The white cell count is 22. Most of yours I hope is between four and 11. So her white cell count is up. So, therefore, between ectopic pregnancy and acute P ID. Now, I hope you would say acute P ID. OK. What are your answers for? Number uh two, question two. It's predominantly a, with a few with C if you would see. OK. So this is a woman. She's 34 uh smokes bleeding pain. So uh I didn't cover this in the lecture. Uh But smoking is a risk factor for ectopic pregnancy. Feeling faint, which is also the next question. Uh So feeling faint and shoulder to pain are quite sensitive markers for ectopic pregnancy. So she felt faint. She'd never been pregnant. Her last bleeding was three weeks ago, didn't say that it was normal or not. And so the most appropriate bedside or near bedside test that you should undertake for her first, the first thing you should do. So with the first thing you would do, would it be a heg blood test or would it be her BP? Because I think it would be her BP. So she's had bleeding and pain and she felt faint. So she's at, she's pointing towards an ectopic pregnancy and therefore doing her BP and seeing what that is would probably be the first thing I would do and check her pulse. And then once you know, she's stable, then think about a RB. Actually, I would think about A or C as being the very accurate test to do that makes sense. And then finally to number three, I've already given you the answer. But what, what do people say? We've got 55% say a 11% C 11% D and 22% e the 11% of you who said fainting and shoulder to pain are, are the in this situation the, the right 11% well done. Um So pain, uh pain is due to many things and lots of things will, will cause pain in early pregnancy, whether it's unilateral or bilateral. Um, hypotension generally is caused by some blood loss. Um, and vaginal bleeding clearly is related to a pregnancy problem. But the most, the thing that's most likely to lead to the diagnosis thing that's most sensitive as a clinical test is fainting and shoulder tip pain. Now, you might say, well, you didn't say that in your lecture and you're right. I didn't, but I put this question in here deliberately to bring out that point that this is a hugely important sign to ask about. So, and if you don't ask it, she won't tell you because she won't associate pain in her left shoulder or her right shoulder with what's going on in her vagina and the blood coming out. So it's much more important I think to try to um focus on that. So I'm sorry for uh stop sharing. Uh I'm sorry that I didn't tell you those answers as we came through, but it's useful uh to um to pick on those as really important symptoms and signs. OK. So can we close that pole down? Yep. It's all done. So you just need to hit, probably answer later or something like that. So, I've got a few questions for you, David. I've got um Rayna asks after given MTX for conservative method and the pregnancy stops, will you advise giving antibiotics to prevent risk of infection from the non viral pregnancy. Um That's a good question. Um, so the pregnancy is non viable, therefore, it's dead. Therefore, it's potentially a source or, um, you know, a site of infection. So, despite that, um, I would probably not give her antibiotics and the reason would be is that if you think about where it is, it's about 86 or eight, less than 10 centimeters because that's a less, a less English or Irish way to think. Um So it's probably about 10 centimeters away from the cervical canal and the cervical canal is a good barrier to infection. The uterine lining is a good barrier to infection. So the likelihood of any antibiotic is getting up there is quite and are not antibiotics, any organisms getting up there that would cause infection is very small. Um So I would probably say no. Ok, perfect. Um Rink you asks um Salt toy, please explain the risks of a repeat ectopic and persistent troph. Ok. So that's a good question. So, so it's so for self fungo, what are the risks of doing that? And what are the risks of the trophoblastic tissue continuing? So, the trophoblastic tissue. So for those of us who don't know is the pregnancy tissue. Um So it, so uh if you remember back on the slide about the likelihood of success of um methotrexate that, that has a success rate of about 75% the same is roughly true for a, a Salpingo um and probably four in five women will have falling levels of HCG and will have trophoblastic tissue that will die and will not continue. You will still be left with a small proportion for whom the HCG levels may fall and then plateau or actually fall and then rise again. So for those people, I think if it falls and plateaus, um I'd be inclined to give methotrexate because um I think that's probably a reasonable approach to take if it falls and then goes back up again. I think that says that your first treatment didn't work and you probably need now to do a salpingectomy which will mean another operation for her. Yes. Um And that will be the end of it. Does that answer that question? I hope so. So, if it's not clear, then put another question up. Perfect. I have another question from Toyo is the care sign which indicates peritoneal irritation in regards to the shoulder pain. Now, that's a really good question because uh I will admit to s snowing, but I don't know what care sign is. I'm just looking it up because I have Google in front of me. Um Care sign describes the pain referred on the left shoulder. Yeah. So yes, uh come back. So that is care sign. But, you know, I wouldn't uh I, I've never used that name uh as the sign for it. And I, you know, I think shoulder tip pain. You know, last week I thought a lot about the terminology you should use. If you're phoning your boss at home who's asleep or if you're trying to get them to respond to your thing. And if you say, and she's positive for care sign and if it's like me, I think what's care sign. But if you said to me she's got shoulder tip pain. I'm thinking she's got an ectopic pregnancy. So I think so. That is the sign. That is what it is. I would prefer you, you didn't use names like that because they can be confusing if you're not completely sure. So I guess, you know, we think about things like acute appendix, acute, acute appendicitis. Um and we think about the site of that pain, um and the site of the pain in acute appendicitis uh is mcburney's point. Um And we all know, I hope what mcburney's point is. Um, ok, Joshua, I see your question. I'll come back to that. But mostly I think, you know, using those kind of um names to describe things are generally regarded as not helpful, I would say. So Joshua asked the question, is the clinical scenario painted in question one. Is it possible? The PID is a sequel to rupture op of pregnancy? But so let me just go back to the question. I'm not sharing. I'll just read it out again. Woman presents with her husband presents to emergency department, abdominal pain, grumbling uh period 25 days. So this woman, this woman has vital signs that are normal. She's not anemic. Um Her hemoglobin is normal and she would be very unlikely to have to have a ruptured ectopic pregnancy and to have normal vital signs. I've never, well, I never, you should never say never. But I cannot recall ever. Somebody uh with a ruptured ectopic who was not hypovolemic who was not in shock even to and, and even if they weren't hypovolemic, their hemoglobin would be 10 or 11. Um Yeah, so I don't think the P ID is uh is a sequel to that. No. Perfect. Does anybody have any other questions? I think we all know what we do. We put them in the chart if you do. I think that's, oh no, I think that's probably us. Thank you everyone for using the chat. We will sort out the polls maybe for next week. We'll put them in the polls so that the question is actually in there and the answers are in there. Maybe. Do we need a bit of time before that to do that? Because I have the lecture done. You can just email them to me and I'll pop them in for next week, next person and I will send you the PDF of today's lectures with the, with what I think are the right answers highlighted. Interestingly for the one about, um for question three, the one about the fainting and shoulder to pain. I had a, a retired colleague, uh staying with me the last couple of days and we were chatting about giving this lecture on Friday and I said to him, you know, so I tested him out. Um, and uh he agreed that the fainting and shoulder to pain was the most indicative of the ectopic pregnancy. So, there you go. Thank you for your comments. David's next event, I'm going to pop it in the chat. Now that is next Friday. We'll be seeing David again and we do have an event this afternoon on ophthalmology. If anybody is interested in that, do you want to come along? I'll be working in the garden feedback form will be in your inbox. Please fill that out. Please do send David some feedback. He really appreciate it. All right and have a great weekend everyone and we will hopefully see you next week. Take care everyone. Bye bye, sir.