Ectopic

Question 1

Absolute contraindications to MTX (4)

Answer 1

Question 2

Relative contraindications to MTX (4)

Answer 2

Question 3

MOA of MTX

Answer 3

Folate antagonist –> dihydrofolate reductase inhibitor –> can’t make purines –> inh DNA synthesis

Question 4

risk of recurrent ectopic with one prior? risk with two or more prior?

Answer 4

One prior = 10%
2+ = 25%

Question 5

Up to ___ of pregnancies with an IUD are ectopic

Answer 5

53%

Question 6

Serum Hcg levels inc until a plateau is hit at ___ by ___ wks gestation

Answer 6

Serum Hcg levels inc until a plateau is hit at 100k by 10 wks gestation

Question 7

With PUL, if uterine aspiration is performed and no products are seen on path– Hcg is thought to have plateau if lvls dec by less than ___

Answer 7

With PUL, if uterine aspiration is performed and no products are seen on path– Hcg is thought to have plateau if lvls dec by less than 10-15%

Question 8

Single dose vs two dose MTX regimen. Better for which pt?

Answer 8

Single dose = good for low Hcg lvl and shown to have less adverse rxn
Two dose = works better for high initial Hcg, but shown to have more adverse rxn

Question 9

During first few days of MTX Rx, Hcg level may ___ but then should progressively ____

Answer 9

During first few days of MTX Rx, Hcg level may inc but then should progressively dec

Question 10

what lab is assc with high risk Rx failure for MTX

Answer 10

Failure of Hcg to dec by at least 15% from day 4 to 7 after MTX is assc with high risk Rx failure

Question 11

resolution of hcg levels after med management of ectopic is usually complete in ___-___ weeks but can take up to ___ weeks

Answer 11

resolution of hcg levels after med management of ectopic is usually complete in 2-4 weeks but can take up to 8 weeks

Question 12

adverse effects of MTX

Answer 12

1. GI upset- n/v, stomatitis
2. vaginal spotting
3. abd pain assc with death of ectopic

RARE- alopecia, elev LFT, pneumonitis

Question 13

what counseling should you give after MTX admin? (4)

Answer 13

1. risk of ectopic rupture and signs
2. avoid high folate foods
3. avoid pregnancy
4. avoid sex and intense activity- risk of rupture

Question 14

how long should you avoid pregnancy after MTX?

Answer 14

1. FDA = at least one ovulatory cycle
2. some experts say at least 3mo

WHY? MTX cleared from serum in 4-12wks but might stick around in liver cells

Question 15

medical management of ectopic is cost effective when ___ ____ ____ to make dx and hCG is less than ___

Answer 15

medical management of ectopic is cost effective when laparoscopy not needed to make dx and hCG is less than 1500

if time to resolution is suspected to be long or if medical management is likely to fail– go with surgery

Question 16

when should salpingostomy for ectopic be considered?

Answer 16

pt desires future fertility and contra-lateral tube is compromised

salpingostomy assc with higher rate of subsequent fertility AND higher rate of repeat ectopic

Question 17

what can you do if you do salpingostomy for ectopic, but there is concern for residual tissue?

Answer 17

single dose prophylactic MTX

Question 18

who is candidate for expectant management of ectopic?

Answer 18

asymptomatic with very low HCG and nothing on US

when hcg <200, 88% of pt will experience spontaneous resolution

Question 19

Single dose MTX regimen

Answer 19

Question 20

Two dose MTX regimen

Answer 20

Question 21

Multi dose MTX regimen

Answer 21