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Maternal > Ectopic pregnancy pt.2 > Flashcards

Ectopic pregnancy pt.2 Flashcards

1
Q

What are the risk factors for nontubal EPs?

A
  • Overall, the risk factors for ovarian EPs, interstitial EPs, and tubal HPs are similar to those for tubal pregnancy.
  • Intramural risk factors include myometrial injury following uterine curettage, and prior myomectomy or cesarean section
  • Cesarean section EP (scar pregnancy) Risk factors: ?
    no clear correlation to the number of prior cesarean sections
  • Cervical EP risk factor: dilation and curettage (D&C) in a previous pregnancy
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2
Q

What does the diagnosis of EP begin with?

A
  • The diagnosis of EP often begins with the preliminary
    diagnosis of pregnancy of unknown location (PUL)
  • PUL is defined as a positive serum beta-human chorionic
    gonadotropin (β-hCG) assay without ultrasound findings of intrauterine or extrauterine pregnancy.
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3
Q

What is a pregnancy of unknown location?

A

PUL is defined as a positive serum beta-human chorionic gonadotropin (β-hCG) assay without ultrasound findings of intrauterine or extrauterine pregnancy.

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4
Q

What happens to PULs?

A 
Approximately 30 % of PUL will become an ongoing
intrauterine pregnancy (IUP), while the majority of them (50– 70 %) will be finally diagnosed as either miscarriage or EP.
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5
Q

When is ß-hCG detectable in serum?

A

From 8 th day after

fertilization.

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6
Q

How do the values beta-hCG in EP pregnancies differ from eutopic pregnancies?

A
  • The serum values of beta-hCG are lower in EP than in
    eutopic pregnancies, even if .
  • About 20% of EP shows
    normal values of beta-hCG for gestational age.
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7
Q

What is very important to do when making a diagnosis of EP?

A
  • It’s essential to carry out serial serum hCG assays
  • In 93% of EP the increase of ß-hCG values is less than 66% after 48 hours (in normal pregnancy the values of ß-hCG doubles every 48 hours!)
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8
Q

When is it possible to identify intrauterine pregnancy using transvaginal ultrasound based on ß-hCG ?

A
  • When serum Beta HCG levels are above 1000-2000 IU / L

- So-called “discriminatory zone”

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9
Q

What would a serum ß-hCG levels above 1000-2000 IU/L with no evidence of intrauterine gestational sac by TV ultrasound suggest?

A

EP has to be suspected

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10
Q

What is needed to make a EP diagnosis?

A

The use of both TV ultrasound and serum beta
HCG assay allows to make a diagnosis of ectopic
pregnancy in 90% of cases.

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11
Q

How does the endometrium appear on TV ultrasound in case of EP?

A

Hyperechoic and moderately thickened (“the empty uterus sign”).

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12
Q

What are observations that can be made using a TV ultrasound on tubal EP?

A
  • Gestational sac and yolk
    sac (and fetal pole, with or
    without cardiac activity) or
    a hyperechoic ring—called
    the ‘tubal’ sign—with
    circumferential Doppler
    flow (Hyperechoic trophoblast
    surrounding the gestational
    anechoic sac)
  • This suspicious mass moves separately from the ovary— called the ‘blob’ sign
  • The visualization of pelvic fluid, particularly in the
    Douglas pouch, is suggestive of the presence of blood and / or clots and therefore suggests
    rupture at the ectopic implantation site.
    -The presence of free fluid in the abdomen often
    constitutes an indication to immediate surgical
    management of the patient.
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13
Q

What can ectopic pregnancies be divided into clinically?

A

Acute (ruptured EP) and unruptured

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14
Q

What are clinical features of acute ectopic pregnancy?

A
  • Amenorrhea
  • Abdominal pain
  • Vaginal bleeding
  • Hypotension
  • Hemorrhagic shock
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15
Q

What are clinical features of unruptured ectopic pregnancy?

A 
• Most often accidental
diagnosis
• Presence of amenorrhea with
signs of pregnancy
• Mild pain or no pain
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16
Q

Why is location of the pregnancy important in ectopic pregnancies?

A
  • The identification of the exact location of an ectopic
    pregnancy facilitates the optimal management
    planning.
  • Especially in uterine ectopic pregnancies the exact location of the gestational sac within the uterine cavity and
    the degree of myometrial involvement are critical features to assist in offering women the choice between
    conservative and surgical management.
17
Q

What is does the treatment of EP consist of?

A

Consist of medical management (single-dose systemic methotrexate) or alternatively surgical removal of the pregnancy

18
Q

What are the benefits of using medical vs surgical management in EP?

A

MTX in comparison to Surgery:
• more cost-effective than surgical management
• similar treatment success and future fertility

19
Q

What is expectant management in the context of EP?

A
  • The American College of Obstetricians and Gynecologists
    recommends that well-counseled, stable patients with EPs and serum β-hCG less than 200 mIU/mL and decreasing (though this
    is not strictly defined) are potential candidates for expectant
    management.
  • Patients must be reliable for follow up, and willing and able to accept the risks of EP rupture, hemorrhage and emergency
    surgery.
20
Q

What is methotrexate?

A

Dihydrofolate reductase inhibitor inhibiting cell division by interfering with DNA replication;

21
Q

What does methotrexate target?

A

It targets rapidly dividing cells and, in case of EP, disrupts primarily trophoblastic tissue

22
Q

What are side effects of methotrexate?

A
  • The most common side effects: pelvic pain, nausea, headaches, abdominal pain, and dermatitis.
  • Less common side effects include mucositis, diarrhea, and alopecia.
23
Q

What are absolute contraindications against EP treatment with MTX?

A
  • Clinical instability or significant pain suggestive of ruptured EP
  • Heterotopic pregnancy with viable and desired IUP
  • Liver function tests more than 2 times the upper limit of normal
  • Platelet count <100,000/uL
  • Creatinine >= 1.5mg/dl
  • Moderate to severe anemia
  • White blood cell count <1500/uL
  • Current breastfeeding
  • Active pulmonary disease
  • Active peptic ulcer disease
  • Sensitivity to methotrexate
24
Q

What are absolute contraindications against EP treatment with MTX?

A
  • Presence of fetal cardiac activity
  • ß-hCG level over 5000 mIU/mL
  • An ectopic mass size greater than 4 cm in largest dimension
  • Patient refusal of blood transfusion
  • Patient inability to follow up
25
Q

Describe the protocol for the use of single dose methotrexate for treatment of ectopic pregnancy

A

Single dose MTX treatment protocol:
Day 1:
- Labs: ß-hCG level, safety labs (CBC with differential, BUN, creatinine, AST, ALT), blood type, and antibody screen
- Action: Give MTX (50mg/m2 of body surface IM)
Day: 4
- Labs: ß-hCG level
- Action: None
Day: 7
- Labs: ß-hCG level and safety labs
- Action:
*ß-hCG decline <15% from Day 4 to Day7: MTX, return to day 1 of protocol. Repeat MTX up to a total of 4 doses
* ß-hCG decline >15% from Day 4 to Day7: Check ß-hCG at 1 week intervals until zero
Two dose methotrexate treatment protocol:
Day1:
- Labs: Same as single dose protocol
- Actions: Same as single dose protocol
Day 4:
- Labs: ß-hCG levels and safety labs
- Action: Give MTX (50mg/m2 of body surface area IM)
Day 7
- Labs: Same as single dose protocol
- Action:
*ß-hCG decline <15% from Day 4 to Day7: Give MTX
* ß-hCG decline >15% from Day 4 to Day7: Check ß-hCG at 1 week intervals until zero
Day 11:
- Labs: ß-hCG levels
- Actions:
*ß-hCG decline <15% from Day 7 to Day 11: Give MTX
* ß-hCG decline >15% from Day 7 to Day 11: Check ß-hCG at 1 week intervals until zero
Day 14:
- Labs: ß-hCG levels and safety labs
- Actions:
*ß-hCG decline <15% from Day 11 to Day 14: Give Refer to surgery
* ß-hCG decline >15% from Day 11 to Day 14: Check ß-hCG at 1 week intervals until zero

Multiple dose methotrexate and leucovorin treatment protocol
Day 1: 
- Labs: Same as single dose protocol
- Actions: MTX (1 mg/Kg, IM)
Day 2: 
- Labs: None
- Actions: LEU (0.1mg/kg, IM)
Day 3: 
- Labs: ß-hCG levels
- Actions:
       *ß-hCG decline <15% from Day 1 to Day 3: Give MTX
      * ß-hCG decline >15% from Day 1 to Day 3: Check ß-hCG at 1 week intervals until zero
Day 4: 
- Labs: None
- Actions: Give LEU
Day 5:
- Labs: ß-hCG levels
- Actions: 
     *ß-hCG decline <15% from Day 3 to Day 5: Give MTX
      * ß-hCG decline >15% from Day 3 to Day 5: Check ß-hCG at 1 week intervals until zero
Day 6:
- Labs: None
- Actions: Give LEU
Day 7: 
- Labs: ß-hCG levels
- Actions: 
     *ß-hCG decline <15% from Day 5 to Day 7: Give MTX
      * ß-hCG decline >15% from Day 3 to Day 5: Check ß-hCG at 1 week intervals until zero
 Day 8: 
- Labs: None
- Action Give LEU
26
Q

What is leucovorin?

A

Medication used to decrease the toxic effects (against bone marrow suppression or gastrointestinal mucosa inflammation) of methotrexate and pyrimethamine

27
Q

What is leucovorin also known as?

A

Folinic acid

28
Q

What is the most important determinant of failure of medical treatment using single dose methotrexate?

A
  • In clinically stable women, the beta- hCG concentration at presentation is the most important determinant of failure of medical treatment
  • Results support a substantial increase in failure of medical management with single-dose methotrexate when the initial hCG is above 5,000 mIU/mL.
  • Methotrexate should be used with caution in patients with ectopic pregnancy who present with hCG levels above this level.
29
Q

How long does it take for ß-hCG levels in ectopic pregnancies to normalize using methotrexate?

A

On average, the β-hCG normalizes in 2 to 3 weeks, but can take up to 8
weeks in patients with higher starting β-hCG levels

30
Q

What are some guidelines regarding methotrexate treatment?

A

Regardless of which treatment regimen is chosen:
- If the β-hCG level does not decline adequately or
in case of hemodynamic instability or pain, surgical management should be considered (high risk of rupture of EP).
- If serum β-hCG declines adequately the β-hCG level should be monitored
weekly to an undetectable level.

Maternal (9 decks)

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