ectopics Flashcards
A 30 yo patient, LMP 6 weeks ago, is at a job interview when she becomes aware of the new onset of worsening, intermittent LLQ pain. After the interview, she notices she is near a hospital and decides to visit the Emergency Department.
Vital signs are within normal limits. Pelvic exam demonstrates a tender and enlarged L adnexum.
A UCG is positive. Serum bHCG=3200 mIU/ml. U/S of the pelvis shows no IUP. There is a complex L adnexal mass.
A gynecologic consultant sees the patient and she is booked for laparoscopic salpingectomy.
as she is being moved to the OR, she suddenly complains of feeling dizzy
-upon arrival in the OR she has no measurable BP
-pt undergoes exploratory laparotomy with L salpingectomy
-estimated blood loss = 2000cc
-pt is admitted to ICU for management of hypovolemic shock due to hemorrhage and receives 2 units of packed RBCs
-she is discharged to home the following day
-when the pt entered the OR was she hemodynamically stable -> no
unstable patient ectopic
-exploratory laparotomy
-stable -> laparoscopic resection
ectopic pregnancy
-pregnancy located other than the uterus
-MC located in the Fallopian tube
-However, they may exist in:
-ovary
-cervix
-abdominal cavity
-old Caesarean scar
-myometrium
-can be heterotopic (a twin gestation with one of which intrauterine twin and one of which is ectopic)
epidemiology and etiology of ectopic pregnancy
-1 in 80 of all gestations (1.25%)
-Risk factors include hx of:
-PID that causes scarring in tubal lumina -> pt may not be aware of this hx
-Endometriosis
-Adenomyosis
-Pelvic adhesions (surgical, post-infectious [appendicitis, etc.])
-Infertility or assisted reproductive technology
ectopic pregnancy
-ectopic pregnancy is MCC of death in the 1st trimester!!!!
-one must always rule out an ectopic pregnancy if you have considered it as a diff dx
potential locations of ectopic pregnancy
triad of signs and sx of ectopic pregnancy
-amenorrhea
-unilateral pelvic pain
-vaginal spotting
-not all pts will present with all components of the triad
surgical management of ruptured ectopic pregnancy
-!!!!Hemodynamically unstable pts require LAPAROTOMY
-Stable pts -> even those with ruptured ectopics -> laparoscopic resection
-Possible procedures:
-Partial salpingectomy
-Total salpingectomy
-Salpingostomy
-management must be individualized
L tubal pregnancy seen on US
L sided ectopic, +FH seen on u/s. Note empty endometrial cavity
salpingectomy
pregnancy of unknown location
-+ pregnancy test -> transvaginal US shows no intrauterine or ectopic pregnancy
-location unclear at presentation (and even at conclusion of initial workup)
-Not all ectopics involve rupture
-Sx and signs may be more mild and subtle
-They include:
-Pelvic pain
-Vaginal bleeding
-pt will have positive urine pregnancy test
-Keep a high index of suspicion!
workup of pregnancy of unknown location
-Serum quantitative HCG
-Transvaginal ultrasound
-Determine if pt wishes to continue the pregnancy
-If yes -> and pt is hemodynamically stable -> offer serial HCG levels every 48 hours
-HCG should double every 48 hours
-When HCG is >1500 mIU/ml -> obtain repeat transvaginal US
todays thursday -> 2000 hcg monday
management options for pregnancy of unknown location: methotrexate
-Destroys rapidly growing tissue by interference with DNA synthesis
-Dose based on body surface area and is calculated by use of a nomogram (or consult a pharmacist)
-avoid green leafy vegetables while taking methotrexate (folate)
-Check bHCG on days 1,4, 7 and then weekly until 0
-Contraindicated in:
-Pts with liver disease or who must take folic acid
-bHCG >15,000 mIU/ml (relative contraindication)
-Fetal cardiac activity outside uterus
-Adnexal mass >4 cm
-Free fluid in cul-de-sac (indicating impendingor present rupture)
-> surgery
management options for pregnancy of unknown location: surgery
-pregnancy may be intrauterine or ectopic (or, very rarely, both) -> first empty the uterus -> pathologist examines during
-if no tissue found intrauterine / hcg doesnt go down -> ectopic -> laparotomy
-Dilation and suction curettage is a less invasive procedure than is laparoscopy
-Obtain frozen section (immediate eval by
pathologist to determine if there are products of conception present)
-If products are present -> workup / management are complete
-If no products present -> laparoscopy
-Remember, tissue is the issue!
-Always follow up pathology results
-uterine evacuation (dilation and curettage) -> frozen section of curettings -> laparoscopy -> laparoscopic salpingectomy, if ectopic is found
which of the following is an absolute contraindication to the use of methotrexate in the tx of an ectopic gestation
-bHCG > 5,000
-vaginal bleeding
-fetal heartbeat seen in adnexa
-adnexal mass of >2.5cm!!!!!!!!!!!
