Ectopic pregnancy Flashcards
What are relative contraindications to methotrexate?
Embryonic cardiac activity detected by transvaginal ultrasonography
High initial hCG concentration (>5000)
size >4cm on US
Refusal to accept blood transfusion
What are absolute contraindications to methotrexate?
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
What is the single-dose regimen for MTX?
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
What is the two-dose regimen for MTX?
— 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.
What is the fixed multiple-dose regimen for MTX?
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
What is the discriminatory HCG value at which the sensitivity of the U/S for detecting an IUP approaches 100%?
typically 1500-3000 mlU/ml
What is the mechanism of action of Methotrexate?
What are side effects?
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.
What factors would predict that medical treatment would fail?
HCG > 5000 mlU/ml
Free fluid
Cardiac activity
Size > 3.5 – 4 cm
What is HCG units?
What is HCG titer rise?
mIU/mL (milli-international units per milliliter)
2x every 48hr until 6 wks pregnancy then >6 weeks, rate of increase slows to doubling q72hr.
What are facts about ectopic?
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.
What is a heterotypic pregnancy?
<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
What are risks of ectopic pregnancy with the following:
ART
IUD
1 or 2 prior ectopic
tubal surgery
s/p BTL
ART=5%
IUD (<20% w/ copper, >20% w/ LNG-IUD)
1 prior ectopic: 10%, 2 is 25%
tubal surgery 20%
s/p BTL: 50%
What causes a false positive HCG?
What is workup?
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 about possible ectopic pregnancy/amenorrhea w/ clomiphene/LLQ adnexal mass, what is differential?
- 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)
When should you do surgical management of ectopic?
- TVUS clearly shows tubal ectopic or adnexal mass suggestive of ectopic
- pt doesn’t want MTX or can’t follow-up
