EM OB 10: Ectopic Pregnancy Flashcards
most important consideration among obstetric-related conditions in the first 20 weeks of pregnancy until it can be either confirmed or excluded with conviction
ectopic pregnancy
The sensitivity of quantitative serum testing for the diagnosis of pregnancy is virtually 100% when an assay is capable of detecting:
≥5 mIU/mL of B-hCG
a leading cause of maternal death in the first trimester of pregnancy
ruptured ectopic pregnancy
Death results from maternal exsanguination after tubal rupture.
maternal age ______ is a major risk factor for ectopic pregnancy
35-44y
(age-related change in tubal function)
TRUE or FALSE
Missed menses are always reported in ectopic pregnancy
FALSE
No missed menses are reported in 15% of ectopic pregnancy cases.
remarks on pregnancy in a patient with prior tubal surgery for sterilization
Pregnancy in a patient with prior tubal surgery for sterilization is assumed to be an ectopic pregnancy until proven otherwise.
Most common symptom of ectopic pregnancy
abdominal pain or discomfort
remarks on B-hCG in pathologic pregnancies
Absolute levels of B-hCG are lower and doubling times longer in ectopic pregnancy and other abnormal pregnancies
hCG levels that fail to increase by 53% or more in 2 days are suggestive but not diagnostic of ectopic pregnancy or an abnoramal IUP.
most pathologic pregnancies have progesterone levels of:
</=10 ng/mL
with progesterone ≤5 ng/mL, nearly 100% of pregnancies will be pathologic
but still, the role of serum progesterone assays in excluding or definitively diagnosing ectopic pregnancy is currently unclear
Progesterone levels _____ have 97% sensitivity for viable IUP.
> 25 ng/mL
what is a viable IUP
an embryo with cardiac activity seen within the uterine cavity is referred to as viable IUP
Transvaginal UTZ timeline in visualization of early sonographic signs of pregnancy
4.5 weeks: gestational sac
5.5 weeks: yolk sac
6.0 weeks: fetal pole
Visualization by transabdominal scanning can be done approx 1 week later
this sonographic finding confers a risk of ectopic pregnancy near 100%
the combination of an echogenic adnexal mass with free fluid in the setting of an empty uterus confers a risk of ectopic pregnancy near 100% (97%)
whereas a large amount of free fluid alone [already] has an 86% risk
TRUE or FALSE
The finding of hepatorenal fluid has ~100% risk of ectopic pregnancy in high-risk patietns
TRUE
(Table 98-4)
Describe discriminatory zone
The discriminatory zone is the level of B-hCG at which findings of an IUP are expected on US.
A B-hCG level higher than the discriminatory zone and an empty uterus on US suggest an ectopic pregnancy
discriminatory zone for transvaginal scanning
B-hCG of 1500 mIU/mL
discriminatory zone for transabdominal scanning
B-hCG of 6000 mIU/mL
Most frequently used surgical approach for ectopic pregnancy
laparoscopic salphingostomy
most frequently used medical approach for ectopic pregnancy
systemic methotrexate
- folic acid antagonist that inhibits dihydrofolate reductase, causing depletion of cofactors needed for DNA and RNA synthesis
- IM is the most commonly used approach (50 mg/m2 single dose or multiople doses)
Absolute contraindications to methotrexate adminsitration
IUP
Evidence of immunodeficiency
Moderate to severe anemia, leukopenia, or thrombocytopenia
sensitivity to methotrexate
active pulmonary disease
active PUD
Clinically important hepatic or renal dysfunction
Breast feeding
Hemodynamic instability
Relative contraindications to methotrexate administration
Embryonic cardiac activity detected by transvaginal US
hCG >5000 mIU/mL
ectopic pregnancy >4 cm in size as imaged by transvaginal US
refusal to accept blood transfusion
inability to reliably return for follow up
Most common side effect with methotrexate
abdominal pain (up to 75%)
Lower abdominal pain lasting up to 12 hours is common 3 to 7 days after methotrexate treatment and is though to be secondary to methotrexate-induced tubal abortion or tubal distention due to hematoma formation (“separation pain”)
The pain is usually self-lmitied and may respond to NSAIDs
Other remarks with abdominal pain after methotrexate treatment
a clinical dilemma - still could be rupturing persistent ectopic pregnancy.
It is suggested to test for CBC and do abdominopelvic US to rule out tubal rupture and hemoperitoneium.
Patient may need admission for observation.
RhoGAM in ectopic pregnancy
Recommendations: 50 mcg of RhoGAM for Rh-negative women with ectopic pregnancy when diagnosed prior to 12 weeks of gestation due to small volume of red cells in the fetoplacental circulation, although administration of a full dose of 300 mcg is acceptable as well
