#193 Tubal Ectopic Pregnancy Flashcards
What % of pregnancies are ectopic pregnancies?
Approximately 2%
Ruptured ectopic pregnancy accounts for what % of all pregnancy-related deaths?
2.7%
What is the approximated prevalence of ectopic pregnancy among women presenting to an ED with first-trimester VB, or abdominal pain, or both?
as high as 18%
Where is the most common location for an ectopic pregnancy? What %
The fallopian tube. More than 90% of cases
What % of ectopic pregnancies are abdominal ectopic pregnancy?
1%
What % of ectopic pregnancies are cervical ectopic pregnancy?
1%
What % of ectopic pregnancies are ovarian ectopic pregnancy?
1-3%
What % of ectopic pregnancies are cesarean scar ectopic pregnancy?
1-3%
What is a heterotopic pregnancy?
An ectopic pregnancy and intrauterine pregnancy co-occurring
What is the risk of heterotopic pregnancy in women with naturally achieved pregnancy? With IVF pregnancy?
1 in 4,000 to 1 in 30,000 in naturally occurring. As high as 1 in 100 in IVF pregnancy.
What proportion of women diagnosed with ectopic pregnancy have no risk factors?
One half
What is the risk of an ectopic pregnancy in woman with one prior ectopic pregnancy? With two prior?
10% with one prior. More than 25% with 2 prior.
What are risk factors for an ectopic pregnancy?
Prior ectopic, previous fallopian tube damage, factors secondary to ascending pelvic infection, prior pelvic or fallopian tube surgery, hx of infertility, pregnancy with IUD in place (overall lower rate of ectopics with IUDs in general). ART w/ multiple embryo transfer or w/ hx of tubal factor infertility. Less significant risks: hx of cigarette smoking, age >35yo
What % of pregnancies that occur with IUDs in place are ectopic?
Up to 53%
Do most ectopic pregnancies present with gestational sac with yolk sac, or embryo, or both in adnexa?
No. Most do not progress to this stage
What is the typical ultrasound finding of an ectopic pregnancy?
A mass or a mass with hypoechoic area that is separate from the ovary
How early can you visualize an early intrauterine gestational sac?
As early as 5 wks
What on ultrasound definitively confirms an IUP?
Visualization of a gestational sac with a yolk sac or embryo
What is a pseudogestational sac?
A collection of fluid or blood in the uterine cavity that is sometimes visualized in women with an ectopic pregnancy
When should an intrauterine gestational sac with a yolk sac be visible on ultrasound?
Between 5 wks and 6 wks of gestation.
What is a discriminatory level (re: early pregnancy)? What value should be used?
hCG value above which the landmarks of a normal IUP should be visible on US. As high as 3500 mIU/mL.
At how many weeks gestation and at approx what value does beta hcg plateau?
Plateau of 100k mIU/mL by 10wks gestation
What is the expected rate of increase in beta hcg if initial value is <1500 mIU/mL?
49%
What is the expected rate of increase in beta hcg if initial value is 1500-3000 mIU/mL?
40%
What is the expected rate of increase in beta hcg if initial value is >3000 mIU/mL?
33%
What % of normal pregnancies will have a rate of increase in hcg faster than the minimums (49, 40, 33%)?
99%
How much should you expect a beta hcg to decrease in 2 days in women with a failing pregnancy?
21-35% depending on initial hcg levels (seen in approx 95% of women with this presentation)
In patients with pregnancy of unknown location who have progressing IUP reasonably excluded, what is a reasonable next step?
Uterine aspiration. Can help distinguish early IUP loss from ectopic pregnancy by identifying the presence or absence of intrauterine chorionic villi
When doing uterine aspiration on patient with pregnancy of unknown location, what are you looking for?
Chorionic villi
What is the next step if uterine aspiration for pregnancy of unknown location shows chorionic villi?
No further evaluation necessary, failed IUP is confirmed
What is the next step if uterine aspiration for pregnancy of unknown location does not show chorionic villi?
hcg levels should be measured, with first measurement taken in 12-24h after aspiration.
- if increase or plateau (decreased by less than 10-15%), suggests incomplete evacuation vs nonvisualized ectopic pregnancy
- large decrease in hcg, suggests failed IUP (50% or greater)
What is the next step in management if uterine aspiration for pregnancy of unknown location has no chorionic villi and hcg 24h after procedure decreased by 50%?
Serial hCG measurements, with further treatment reserved for those whose levels plateau or increase, or who develop symptoms of ectopic pregnancy
What is the next step in management if uterine aspiration for pregnancy of unknown location has no chorionic villi and hcg 24h after procedure decreased by 30%?
if hcg decline is 15-50% 12-24h after aspiration, requires close follow -up with serial hCG measurement, with consideration of treatment for ectopic pregnancy based on clinical factors such as plateau or increase in hcg, development of symptoms or high clinical suspicion or strong risk factors for ectopic pregnancy
In patients with pregnancy of unknown location, what is the risk of rupture during surveillance for all women at risk and for those who are diagnosed with ectopic pregnancies?
0.03% risk of rupture among all women at risk. 1.7% risk of rupture among all ectopic pregnancies
What medication is used for medical management of ectopic pregnancies?
Methotrexate
What is the mechanism of action of methotrexate?
Folate antagonist that binds to the catalytic site of dihydrofolate reductase, which interrupts the synthesis of purine nucleotides and the amino acids serine and methionine, thereby inhibiting DNA synthesis and repair and cell replication
What cell lines does methotrexate affect?
Actively proliferating tissues: bone marrow, buccal and intestinal mucosa, respiratory epithelium, malignant cells, and trophoblastic tissue
What is the route of administration of methotrexate for ectopic pregnancy?
Intramuscular
How is methotrexate cleared from the body?
Renal excretion
What are absolute contraindications to methotrexate therapy for ectopic pregnancy?
IUP; evidence of immunodeficiency; moderate to severe anemia, leukopenia, thrombocytopenia; sensitivity to methotrexate; active pulmonary disease; active peptic ulcer disease; clinically important hepatic or renal dysfunction; breastfeeding; ruptured ectopic pregnancy; hemodynamic instability; inability to follow up
What are relative contraindications to methotrexate therapy for ectopic pregnancies?
Embryonic cardiac activity detected by TVUS; high initial hcg concentration (5000 is often used); ectopic >4cm in size by TVUS; refusal to accept blood transfusion
What is the failure rate of methotrexate therapy for ectopic pregnancies if hcg >5000, if <5000?
14.3% failure if hcg > 5000. 3.7% failure rate if hcg < 5000.
What different protocols exist for methotrexate use for ectopic pregnancy?
- Single-dose protocol
- Two-dose protocol
- Fixed multiple-dose protocol
How often is an additional dose of methotrexate required with the single-dose regimen for ectopic pregnancy?
Up to one fourth of patients
What is the single-dose regimen for methotrexate (dosing, testing, results)?
Administer 50mg/m^2 methotrexate on day 1. measure hcg on posttreatment days 4 and 7. If decrease >15%, measure weekly until nonpregnant level. If decrease less than 15% readminister methotrexate and repeat hcg.
What is the two-dose regimen for methotrexate (dosing, testing, results)?
Administer methotrexate 50mg/m^2 on days 1 and 4. Measure hcg level on posttreatment days 4 and 7. If decrease >15%, test weekly until negative. If less than 15% decrease, readminister on day 7 and check hcg on day 11. If <15% readminister methotrexate on day 11, check hcg on day 14. If still < 15%, consider surgery
What is the fixed multiple-dose regimen for methotrexate (dosing, testing, results)?
Administer methotrexate 1mg/kg IM on days 1, 3, 5, 7; administer 0.1mg/kg folinic acid on days 2, 4, 6, 8. Measure hcg levels on methotrexate dose days and continue until hcg has decreased by 15% from previous measurements, can then stop methotrexate admins and check hcg weekly until neg. If not decreased after 4 doses, consider surgery.
How does the side effect profile of single dose methotrexate compare to mutli-dose regimen?
More side effects with multidose
What should you consider in patient with pregnancy of unknown location who failed methotrexate therapy?
If patient did not undergo pretreatment uterine aspiration should raise concern for presence of an abnormal intrauterine gestation, can consider uterine aspiration prior to repeat MTX, unless clear evidence of ectopic
Should you follow ectopic pregnancy with ultrasound to ensure resolution?
Not routinely indicated because findings do not predict rupture or time to resolution
How long after methotrexate therapy should you expect resolution of an ectopic pregnancy?
Resolution of serum hCG after med management is usually complete in 2-4wks, but can take up to 8wks
What are most common adverse effects of methotrexate therapy for ectopic pregnancy? What are less common adverse effects?
Nausea, vomiting, stomatitis are most common. Vaginal spotting is expected. 2-3 days of abdominal pain.
Elevation of liver enzymes, alopecia (rare), pneumonitis
How should you counsel patients who are taking methotrexate?
Counsel about risk of rupture and precautions, avoid repeat pregnancy until resolution confirmed, avoid vigorous activity and sexual intercourse, avoid folic acid supplements, foods that contain folic acid, NSAIDs (may decrease efficacy of MTX), avoid narcotic analgesics, alcohol, and gas-producing foods (as not mask, confuse, or escalate symptoms of rupture). Sunlight exposure should be avoided during treatment to limit risk of MTX dermatitis.
What is the risk of sun exposure after Methotrexate administration?
Methotrexate dermatitis
How long does FDA recommend waiting after methotrexate administration prior to conceiving new pregnancy? How long does “expert” opinion recommend delaying pregnancy?
Avoid pregnancy during treatment and for at least one ovulatory cycle after MTX therapy per FDA. Per expert opinion, recommend delay for at least 3 months
Does methotrexate treatment for ectopic pregnancy have an effect on subsequent fertility or on ovarian reserve?
Not thought to have an adverse effect, but available evidence is limited
Which patients require surgical management of ectopic pregnancy?
Any of the following: hemodynamic instability, symptoms of an ongoing ruptured ectopic mass (such as pelvic pain), or signs of intraperitoneal bleeding; meeting any of the absolute contraindications to med management; failed medical management, etc
What surgical procedures can be performed for a patient with a tubal ectopic pregnancy?
laparoscopic salpingectomy, laparoscopic salpingostomy, laparotomy (typically reserved for unstable patients, large intraperitoneal bleeding, compromised visualization at laparoscopy)
Is medical or surgical management of ectopic pregnancy more cost effective?
Depends. If hcg <1500, medical cheaper. Surgical is cheaper if time to resolution is expected to be prolonged or there is a relatively high chance of medical management failure
What is the next step in management for patient with ectopic pregnancy managed by salpingostomy?
Need to monitor with serial hcg measurements to ensure resolution of ectopic trophoblastic tissue
What is the next step in management for a patient s/p salpingostomy for ectopic pregnancy with concern for incomplete resection?
Single prophylactic dose of MTX may be considered
Who is a candidate for expectant management of diagnosed ectopic pregnancy?
- Asymptomatic
- Objective evidence of resolution (plateau or decreasing hcg)
- Counseled and willing to accept potential risks
- lower hcg (88% of patients w/ hcg <200 will have spontaneous resolution)
