Ectopic pregnancy pt.2 Flashcards
What are the risk factors for nontubal EPs?
- 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
What does the diagnosis of EP begin with?
- 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.
What is a pregnancy of unknown location?
PUL is defined as a positive serum beta-human chorionic gonadotropin (β-hCG) assay without ultrasound findings of intrauterine or extrauterine pregnancy.
What happens to PULs?
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.
When is ß-hCG detectable in serum?
From 8 th day after
fertilization.
How do the values beta-hCG in EP pregnancies differ from eutopic pregnancies?
- 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.
What is very important to do when making a diagnosis of EP?
- 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!)
When is it possible to identify intrauterine pregnancy using transvaginal ultrasound based on ß-hCG ?
- When serum Beta HCG levels are above 1000-2000 IU / L
- So-called “discriminatory zone”
What would a serum ß-hCG levels above 1000-2000 IU/L with no evidence of intrauterine gestational sac by TV ultrasound suggest?
EP has to be suspected
What is needed to make a EP diagnosis?
The use of both TV ultrasound and serum beta
HCG assay allows to make a diagnosis of ectopic
pregnancy in 90% of cases.
How does the endometrium appear on TV ultrasound in case of EP?
Hyperechoic and moderately thickened (“the empty uterus sign”).
What are observations that can be made using a TV ultrasound on tubal EP?
- 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.
What can ectopic pregnancies be divided into clinically?
Acute (ruptured EP) and unruptured
What are clinical features of acute ectopic pregnancy?
- Amenorrhea
- Abdominal pain
- Vaginal bleeding
- Hypotension
- Hemorrhagic shock
What are clinical features of unruptured ectopic pregnancy?
• Most often accidental diagnosis • Presence of amenorrhea with signs of pregnancy • Mild pain or no pain
Why is location of the pregnancy important in ectopic pregnancies?
- 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.
What is does the treatment of EP consist of?
Consist of medical management (single-dose systemic methotrexate) or alternatively surgical removal of the pregnancy
What are the benefits of using medical vs surgical management in EP?
MTX in comparison to Surgery:
• more cost-effective than surgical management
• similar treatment success and future fertility
What is expectant management in the context of EP?
- 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.
What is methotrexate?
Dihydrofolate reductase inhibitor inhibiting cell division by interfering with DNA replication;
What does methotrexate target?
It targets rapidly dividing cells and, in case of EP, disrupts primarily trophoblastic tissue
What are side effects of methotrexate?
- The most common side effects: pelvic pain, nausea, headaches, abdominal pain, and dermatitis.
- Less common side effects include mucositis, diarrhea, and alopecia.
What are absolute contraindications against EP treatment with MTX?
- 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
What are absolute contraindications against EP treatment with MTX?
- 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
