Ectopic pregnancy

Question 1

What are relative contraindications to methotrexate?

Answer 1

Embryonic cardiac activity detected by transvaginal ultrasonography
High initial hCG concentration (>5000)
size >4cm on US
Refusal to accept blood transfusion

Question 2

What are absolute contraindications to methotrexate?

Answer 2

IUP
Evidence of immunodeficiency
Moderate to severe anemia, leukopenia, or thrombocytopenia
Sensitivity to methotrexate
Active pulmonary disease
Active peptic ulcer disease
Clinically important hepatic dysfunction
Clinically important renal dysfunction
Breastfeeding
Ruptured ectopic pregnancy
Hemodynamically unstable patient
Inability to participate in follow-up

Question 3

What is the single-dose regimen for MTX?

Answer 3

Administer a single dose 50mg/m2 IM on Day 1
Measure HCG on day 4 and day 7
If decrease is >15%, measure hcg weekly until 0
If decrease not >15%, administer another dose of MTX 50mg/m2 IM and follow weekly
If HCG doesn’t decrease after 2 doses, consider surgical management

Question 4

What is the two-dose regimen for MTX?
When should you use it?

Answer 4

— consider for HCG >3000 or adnexal mass >2cm

Administer MTX 50mg/m2 IM on day 1 and day 4
Hcg level check on day 4 and day 7
If decrease >15%, measure hcg weekly until 0
If decrease <15%, readminister MTX on day 7 and recheck hcg on day 11
If decrease >15% between day 7 and day 11, monitor weekly until 0
If decrease <15% between day 7 and 11, administer MTX on day 11 adn check on day 14. If doesn’t decrease after 4 doses, consider surgery
Comparable risk of adverse effects as single-dose protocol. Statistically significant higher success rate for 2-dose regimen if initial HCG between 3600 and 5500.

Question 5

What is the fixed multiple-dose regimen for MTX?

Answer 5

weight-based. Administer MTX 1mg/kg IM on days 1,3,5,7; alternate w/ folinic acid (leucovorin) 0.1mg/kg IM on days 2,4,6,8. Folinic acid is a rescue to avoid the side effects of MTX.
Measure hCG on MTX doe days and continue until hcg decreased by 15% from prior level
If decrease >15%, discontinue MTX administration and measure hcg weekly until 0 (may need 1,2,3, or 4 doses). If hcg doesn’t decrease after 4 doses, consider surgery

Question 6

What is the discriminatory HCG value at which the sensitivity of the U/S for detecting an IUP approaches 100%?

Answer 6

typically 1500-3000 mlU/ml

new is 3500?

Question 7

What is the mechanism of action of Methotrexate?

What are side effects?

Answer 7

Anti-metabolite; folic acid antagonist by inhibiting the enzyme dihydrofolate reductase (S-phase dependent)

SE: stomatitis, conjunctivitis.
Rare: gastritis, entertains, pneumonitis, alopecia, elevated LFTs, bone marrow suppression.
- avoid vitamins (folate), nSAIDs, vigorous activity, sex.

Question 8

What factors would predict that medical treatment would fail?

Answer 8

HCG > 5000 mlU/ml
Free fluid
Cardiac activity
Size > 3.5 – 4 cm

Question 9

What is HCG units?

What is HCG titer rise?

Answer 9

mIU/mL (milli-international units per milliliter)

2x every 48hr until 6 wks pregnancy then >6 weeks, rate of increase slows to doubling q72hr.

Question 10

What are facts about ectopic?

Answer 10

after aspiration for PUL, hcg decrease of >50% after 12-24hr=intrauterine process.

• progesterone only significant if < 5
• intrauterine GS + YS seen at 5-6wks.

expectant management: if stable pt with hcg <200, 88% experience spontaneous resolution.

avoid pregnancy for at least 1 ovulatory cycle after MTX.

Question 11

What is a heterotypic pregnancy?

Answer 11

<1/10K pregnancies, more common w/ IVF
- mechanism: transfer of multiple embryos w/ inadvertent flushing of one into cornua/fallopian tube.
- iVF transfer + spontaneous conception simultaneously.

CONSIDER IF:
- iVF transfers
- unexplained bleeding/pain in early pregnancy

Question 12

What are risks of ectopic pregnancy with the following:
ART
IUD
1 or 2 prior ectopic
tubal surgery
s/p BTL

Answer 12

ART=5%
IUD (<20% w/ copper, >20% w/ LNG-IUD)
1 prior ectopic: 10%, 2 is 25%
tubal surgery 20%
s/p BTL: 50%

Question 13

What causes a false positive HCG?
What is workup?

Answer 13

Heterophilic antibodies (usually 2/2 animals - lab technicians or vets)

• Upreg (heterophilic Ab not in urine)
• rerun serum using another assay
• usually seen with levels <1000

Question 14

Question about possible ectopic pregnancy/amenorrhea w/ clomiphene/LLQ adnexal mass, what is differential?

Answer 14

• early IUP w/ implantation bleeding
  -threatened SAB, incomplete or complete SAB
• multiple gestation w/ SAB of one twin
• ectopic
• molar pregnancy
• heterotypic pregnancy

Workup:
-HCG
- T&S
- pelvic US
- CBC, CMP (asses renal/liver function)

Question 15

When should you do surgical management of ectopic?

Answer 15

• TVUS clearly shows tubal ectopic or adnexal mass suggestive of ectopic
• pt doesn’t want MTX or can’t follow-up

Question 16

When would you do salpingectomy over salpingostomy?

Answer 16

Salpingectomy:
- ruptured or bleeding tube
- uncontrolled bleeding
- large gestation >3cm
- avoids need for future tx persistent trophoblast

Salpingostomy
- desire future childbearing (spontaneous iUP rates higher but recurrent ectopic higher)

do laparotomy if corneal ectopic, extensive adhesive disease, hemodynamically unstable

Question 17

What is the management of a surgical ectopic pregnancy?

Answer 17

differential=nabotian cyst, cervical anomaly, leiomyoma, malignancy.

-incr risk hemorrhage, bluish cervix, DON’T do digital exam.
- surgery w/ Type and cross, large bore IV, consent for possible hyst. can try max but risk of hemorrhage (need 3 dose regimen). if bleeding after MTX, do dilation & ECC -> UAE -> hyst.

Question 18

What is management of corneal ectopic pregnancy?

Answer 18

interstitial preg (1-3% of ectopics)
- risk hemorrhage/uterine rupture
- if early ddx, can do medical management (multi dose mTX).
- generally surgical management
- discuss risk of uterine rupture.

• type and cross
• large bore IV
• consent for possible hyst
• LSC corneal resection and uterine reconstruction (or laparotomy if no experience in ldc).
• inject dilute vasopressin into corneal myometrium. remove pOC via grasping forceps or gentle curettage. Close defect.

Question 19

What is proper medical management of undesired pregnancy?

Answer 19

Mifepristone is a selective progesterone receptor modulator and misoprostol is a prostaglandin E1 analogue.

60% of abortions will occur before 10 weeks with current data suggesting that medication abortion constitutes 39% of all abortions

EVAL: confirm dating, T&S, CBC,

Mifepristone: 200 mg | OralMisoprostol: 800 micrograms 24hrs later.

COUNSELING:
Bleeding and cramping may be more severe than menses
Potential adverse effects (typically following misoprostol)
Nausea | Diarrhea | Headache | Dizziness | Thermoregulatory effects (e.g., fever, warmth, hot flushes, chills)
Contact clinician:
Heavy bleeding: Soaking >2 maxi pads per hour for 2 consecutive hours
- In person follow-up not needed
- offer contraception

MEDICATION FAILURE:
Repeat dose of misoprostol or
Uterine aspiration or
Expectant management

Question 20

What is the risk of ectopic pregnancy after IUD and after sterilization?

Answer 20

IUD 20%
sterilization (i.e. BS) 33%

Question 21

What are risks of treating early pregnancy loss before confirmed diagnosis?

Risk factors for miscarriage?

Answer 21

Ectopic pregnancy and not providing proper treatment, or molar pregnancy, or ending a viable pregnancy.

miscarriage: Maternal (DM, obesity, AMA, prior SAB), chromosomal abnormalities. 50% miscarriages due to chromosomal abnormalities.