Chapter 19 Ectopic Pregnancy Flashcards
Most common segment with ectopic pregnancy
A. ampulla
B. isthmic
C. fimbrial
D. interstitial
A. ampulla (70 percent) isthmic (12 percent) fimbrial (1 1 percent) interstitial tubal pregnancies (2 percent)
a condition in which epithelium-lined diverticula extend into a hypertrophied muscularis layer
Salpingitis isthmica nodosa
Clinical manifestation of ectopic pregnancy
- delayed menstruation
- pain (sharp, stabbing, or tearing )
- vaginal bleeding or spotting
discriminatory threshold
1500-2000mIU/mL
B-HCG level for PT +
urine: 20 to 25 mIU/mL
serum: =5 mIU/mL
Serum progesterone excludes ectopic pregnancy
> 25 ng/mL
TV-UTZ Gestational Sac
4 1/2 and 5 weeks
TV-UTZ yolk sac
5 and 6 weeks
TV-UTZ Fetal pole with cardiac activity
5 1/2 to 6 weeks
adnexal finding of an ectopic
Ring of fire doppler
Pericolic gutter near liver
Morison pouch
Methorexate MOA
blocking the reduction of dihydrofolate to tetrahydrofolate —> de novo purine and pyrimidine synthesis is halted, which leads to arrested DNA, RNA, and protein synthesis
Methotrexate side effects
bone marrow, gastrointestinal mucosa, and respiratory epithelium can also be harmed
Methotrexate single dose dosage
50mg/m2 BSA
Methotrexate multidose dosage
1mg/kg days 1,3,5,7
Leucovorin days 2,4,6,8
Methotrexate single dose serum B-HCG monitoring
Days 1,4,7
Once 15% decline achieved then weekly until undetectable
Methotrexate multidose serum B-HCG monitoring
Days 1,3,5,7
Once 15% decline achieved then weekly until undetectable
Single dose indication for additional dose
If serum B-HCG level does not decline by 15% from day 4 to day 7
Less than 15% decline during weekly surveillance
Multiple dose indication for additional dose
If serum B-HCG declines <15% give additional dose then repeat serum BHCG in 48 hours and compare with previous value, maximum 4 doses
Methotrexate surveillance
once 15% decline achieved then weekly serum B-HCG levels until detectable
methotrexate contraindications
sensitivity to methotrexate tubal rupture breastfeeding intrauterine pregnancy peptic ulcer disease active pulmonary disease immunodeficiency hepatic renal or hematologic dysfunction
Increase MTX drug level
phenytoin, tetracyclines, salicylates, sulfonamides , NSAIDs, aspirin, probenecid, or penicillins
Medical therapy indication
- asymptomatic, motivated, and compliant
- small ectopic pregnancy size ectopic mass was<3.5cm,
- absent fetal cardiac activity
- hemodynamically stable
- serum -hCG concentrations <5000 mIU/mL
incision is left unsutured to heal by secondary intention
Salpingostomy
complete excision of the fallopian tube
salpingectomy
expectant management criteria
ectopic pregnancies measuring <3 cm
B-hCG levels < 1 500 mIU/mL
- an empty uterus
- a gestational sac seen separate from the endometrium and > 1 cm away from the most lateral edge of the uterine cavity
- a thin, <5-mm myometrial mantle surrounding the sac
interstitial pregnancy
conception that develops in the rudimentary horn of a uterus with a mullerian anomaly
angular pregnancy
Cornual pregnancy
Spiegelberg criteria
(1) the ipsilateral tube is intact and distinct from the ovary;
(2) the ectopic pregnancy occupies the ovary;
(3) the ectopic pregnancy is connected by the uteroovarian ligament to the uterus;
(4) ovarian tissue can be demonstrated histologically amid the placental tissue
