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MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY Cary L. Clarke, MD Definition Pregnancy located outside the uterus Most common site is in the fallopian tube Tubal pregnancy ...

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Slide 2 - Definition Pregnancy located outside the uterus Most common site is in the fallopian tube Tubal pregnancy may be the most dangerous Abdominal pregnancy may be carried to term in some patients
Slide 3 - Incidence and Impact Occurs in 1 in 50 pregnancies Is becoming increasingly more common Is the second leading cause of maternal mortality overall, and primary mortality factor in first trimester pregnancies May lead to impairment or loss of fertility
Slide 4 - Risk Factors Previous ectopic pregnancy Tubal damage from infection or surgery Increased age (more common after 35) Smoking (?) Use of an Intrauterine Device
Slide 5 - Assisted reproduction (GIFT, IVF, ovulation induction) Tubal ligation History of infertility (implying underlying damage) History of PID (C.Trachomatis especially) is a predictor of ectopic pregnancy risk
Slide 6 - Symptoms (early) Amenorrhea for an average of 7 weeks Abdominal pain (usually lateral) Caveat: some women have no pain, and about one-third of women will not have adnexal tenderness. Vaginal bleeding after an interval of amenorrhea may include uterine cast, the pregnancy endometrium which is sloughed with loss of progesterone from corpus luteum failure
Slide 7 - Symptoms (later) Hemodynamic instability Peritoneal signs/acute abdomen Distended, silent, “doughy” abdomen Shoulder pain
Slide 8 - Pathophysiology Conceptus lodges and implants in tube Positive beta-HCG and symptoms of pregnancy Overdistension of the tube eroding the blood vessels supplying the corpus luteum Failure of the pregnancy Bleeding into the abdominal cavity
Slide 9 - Natural history May regress spontaneously Abortion out the end of the tube Chronic hematoma formation Reimplantation elsewhere (abdominal pregnancy)
Slide 10 - Diagnosis History and physical any woman presenting with pain and vaginal bleeding should be considered to have an ectopic pregnancy until otherwise ruled out
Slide 11 - Laboratory markers Beta-HCG(measured in mIU/mL) --lack of doubling signals only impending failure, not indicative of location;absolute value only helpful in correlation with ultrasound Progesterone--also only indicates impending loss, not location
Slide 12 - Ultrasound--transvaginal is most sensitive at this stage of pregnancy. Correlation with the quantitative serum hormone levels is suggested to increase your sensitivity if intrauterine gestational sac is seen and b-HCG is 1,000-2,000, normal pregnancy is virtually certain. If b-HCG is <1,000 and there is an empty uterus, ectopic pregnancy is very likely
Slide 13 - if b-HCG is is less than 1,000 and definite intrauterine ring of pregnancy is seen, SAB is imminent. Serum progesterone may be helpful (if less than 5ng/mL, pregnancy is nonviable).
Slide 14 - Finding Ectopic risk No mass or free fluid Any free fluid Echogenic mass Moderate to large amount fluid Echogenic mass and fluid 20% 71% 85% 95% 100%
Slide 15 - Treatment Options Surgery Tube sparing salpingotomy--used when gestational sac is <2cm and in distal tube; lateral incision made and gestational sac removed Tube sacrificing salpingectomy Expectant mangagment b-HCG is <1000 and falling, there is minimal pain and bleeding, and patient is reliable for follow-up
Slide 16 - Methotrexate Requires proper patient selection Spares patient from surgery and its risks Does not require hospitalization May help preserve future fertility
Slide 17 - Patient Selection Hemodynamically stable No medical contraindications (normal LFTs, renal function, CBC and Plt) Unruptured ectopic pregnancy Absence of embryonic cardiac activity Ectopic mass 4cm or less Starting b-HCG <5,000mIU/mL Reliable for follow up
Slide 18 - Mechanism of Action Methotrexate is an antimetabolite which inhibits the reduction of folic acid to tetrahydrofolate. This interferes with DNA synthesis and cell multiplication. Ideal for disrupting trophoblastic tissue proliferation.
Slide 19 - Success Rate Defined as resolution of pregnancy without surgery Systemic administration carries a rate between 85% and 95%, with preservation of fertility Single dose regimens are essentially as effective, with fewer side effects If a second dose is required, success rate is around 98%
Slide 20 - Method of administration May inject into the gestational sac under ultrasound guidance Single dose systemic treatment Methotrexate 50mg/M2 body surface area Usual dose range is 50-120 mg, average dose is 80-90mg Injected IM
Slide 21 - Follow up b-HCG is measured on days 1,4 and 7 If hormone levels fail to decline at least 15% between days 4 and 7, or at least 15% each week thereafter, repeat methotrexate dosing. Average time to resolution for single administration, 26days two dose patients, 48 days
Slide 22 - Failure to resolve if the serial quantitative analysis fails to reach near zero levels, patient needs further ultrasonographic evaluation and possible exploratory surgery.
Slide 23 - Surgical Consultation Cervical pregnancy Tubal rupture Broad ligament pregnancy Interstitial/Cornuate pregnancy (implantation at the segment of tube penetrating uterine wall) Heterotypic ectopic (concurrent ectopic and intrauterine pregnancies)