nr 2 Mehl + UW ectopic pregnancy 03-24 (2) Flashcards
UW. What level of hCG has to be to vizualize pregnancy by TVUG?
β-hCG >3,500 mIU/mL
UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. why is it?
because her quantitative β-hCG level (ie, 1,000 mIU/mL) is below the threshold at which an intrauterine pregnancy can be visualized by TVUS (ie, below the discriminatory zone [β-hCG <3,500 mIU/mL]).
UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. so where is pregnancy?
She has a pregnancy of unknown location
UW. last menstr 7 weeks + 1000 hCG + TVUG does not vizualize anything. best next step?
repeat quantitive bhCG in 48 hours.
wrong - tranabdominal UG
UW. last menstr 7 weeks (aka first trimester) + vaginal bleeding + positive hCG (buvo 1000). requires what evaluation? 2
Evaluation with TVUS and serum β-hCG measurements to determine pregnancy location.
UW. The most common cause of a pregnancy of unknown location …..?
early gestation of a normal intrauterine pregnancy.
UW. pregnancy of unknown location other etiologies?
completed spontaneous abortion,
nonviable intrauterine pregnancy (missed abortion), and ectopic pregnancy,
all of which require further evaluation for definitive diagnosis.
UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 1. intrauterine?
Early but viable intrauterine pregnancies typically have a ≥35%-50% rise in β-hCG every 48 hours.
UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 2. complete spontaneous abortions?
Completed spontaneous abortions cause β-hCG levels to decrease precipitously because the pregnancy has been evacuated
UW. Because each type of pregnancy follows a characteristic β-hCG pattern, quantitative β-hCG levels are repeated every 48 hours. 3. Ectopic and nonviable intrauterine pregn.?
Ectopic and nonviable intrauterine pregnancies (eg, anembryonic gestations) usually cause <35% rise in β-hCG due to abnormal pregnancy development.
UW. Patients typically require serial quantitative β-hCG measurements until ……?
the level reaches the discriminatory zone, at which point a repeat transvaginal ultrasound is performed
UW. Those with an abnormally rising β-hCG level require close follow-up due to the risk of ectopic pregnancy.
.
UW. when used methotrexate?
typically used in patients with an unruptured ectopic pregnancy
UW. what is done in ruptured ectopic or contraindications of methotrexate?
hemodynamic instability (ie, ruptured ectopic pregnancy)
or
patients with contraindications to methotrexate (eg, immunodeficiency, breastfeeding).
UW. Educational objective: Patients with vaginal bleeding and positive β-hCG require TVUG to determine pregnancy location.
Patients with a nondiagnostic ultrasound result (eg, no intrauterine pregnancy, free fluid, or adnexal masses) require a repeat quantitative β-hCG level in 48 hours to evaluate for potential ectopic pregnancy.
.
UW. typically have a ≥35%-50% rise in β-hCG every 48 hours.?
Early but viable intrauterine pregnancies
UW. β-hCG levels to decrease precipitously because the pregnancy has been evacuated.?
Completed spontaneous abortions
UW. cause <35% rise in β-hCG due to abnormal pregnancy development?
Ectopic and nonviable intrauterine pregnancies (eg, anembryonic gestations
UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. location of pregnancy? 2
She has pregnancy of unknown location (no visible intrauterine or extrauterine gestation on ultrasound)
Rise of hCG is abnormal (less than < 35 proc. after 48h) = probably ECTOPIC or NONVIABLE INTRAUTERINE PREGNANCIES (eg, anembryonic gestations.
UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. best next step?
pregnancy is ectopic or nonviable.
DO Diagnostic dilation and curettage to differenctiate.
UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage. next step?
evaluate hCG again
UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage, next day β-hCG level is 1,566 mIU/mL.
hCG is increased. what is conclusion? next step?
Persistent rise in β-hCG level after dilation and curettage is diagnostic for an ectopic pregnancy –> additional Mx = HD stable, give methotrexate
UW. case. TVUG negative + hCG is 1,100 mIU/mL and a repeat 48 hours later is 1,370 mIU/mL. + done Diagnostic dilation and curettage, next day β-hCG level is decreased. What is conclusion? next step?
A negative or decreased β-hCG level confirms that the patient had a nonviable intrauterine pregnancy –> reassurance and observation
UW. methotrexate mechanism?
A folate antagonist that inhibits DNA synthesis and cell growth preferentially in rapidly dividing cells (eg, trophoblasts)
UW. methotrexate for ectopic. what is next after you give it?
Require monitoring of β-hCG levels until they become undetectable to ensure that treatment is complete.
UW. when is used misoprostolis/mifespristonas?
cause uterine contractions and are used for the medical management of spontaneous abortions; they are not used to treat ectopic pregnancy.
UW. Misoprostol mechanism?
misoprostol (prostaglandin E1 agonist)
UW. mifepristone mechanism?
Mifepristone (progesterone antagonist)
UW. is progesterone levels important in diagnosing pregnancy/detecting location?
Higher serum progesterone levels are usually associated with normal, viable intrauterine pregnancies (and lower levels with ectopic or nonviable intrauterine pregnancies). However, levels are not diagnostic for ectopic pregnancy due to low sensitivity and specificity; therefore, measurement is not indicated.
UW. educational: Ectopic pregnancy (ie, pregnancy implanted in an extrauterine location) can be diagnosed by a persistent rise in β-hCG level following diagnostic dilation and curettage.
.
UW. 39y/o + vaginal spotting and a positive pregnancy test. Seen 2 days ago: vaginal spotting, β-hCG level of 3,033 mIU/mL, TVUG thickened endometrial stripe with no intrauterine pregnancy or adnexal masses. Today: continues to have vaginal spotting but no pelvic pain or cramping, minimal amount of dark red blood in the posterior vaginal vault Vitals = normal. Now β-hCG 3,582 mIU/mL, TVUG unchanged from the previous findings. Diagnostic dilation and curettage is performed and examination of the intrauterine contents reveals benign endometrial tissue and no chorionic villi. Cause?
ECTOPIC PREGNANCY
note: abnormal rise 3033 -> 3582 (less 35 proc.)
UW. Abnormal intrauterine pregnancy (including a recent complete spontaneous abortion) will have chorionic villi, a finding consistent with intrauterine placental development.
Ectopic pregnancy will have no chorionic villi due to extrauterine pregnancy implantation.
UW. The most common reason for early pregnancy monitoring is first-trimester bleeding, as in this patient with vaginal spotting.
biski siitas mindfuckino
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UW. ectopic pregn. table. risk factors, 3?
Previous ectopic pregnancy
previous pelvic/tubal surgery
PID
UW. ectopic pregn. table. CP 4?
Abdominal pain, amenorrhea, vaginal bleeding
Hypovolemic shock in ruptured ectopic pregnancy
Cervical motion, adnexal and/or abdominal tenderness
+/- palpable adnexal mass
UW. ectopic pregn. table. Dx?
Positive hCG
TVUG - adnexal mass, empty uterus
UW. ectopic pregn. table. MX in stable?
methotrexate
UW. ectopic pregn. table. Mn in unstable?
surgery
UW. ectopic and IUD. risk?
Although patients with an intrauterine device (IUD) have a lower absolute risk for ectopic pregnancy (due to overall lower rates of pregnancy), they are at higher risk for extrauterine implantation if pregnancy occurs.
UW. Pregnancy normally induces endometrial thickening (ie, decidualization) to encourage intrauterine implantation; however, patients with a progestin-containing IUD develop endometrial atrophy (ie, thinning), which can induce amenorrhea but also promote extrauterine implantation.
.
UW. IUD + changes in bleeding pattern.
Case: Hx of heavy menstrual bleeding for which she had a progestin-containing IUD placed 3 years ago. She has been amenorrhoeic for the past 2 years but started having vaginal spotting a few days ago and some mild pelvic cramping.
what suspect??
Because an ectopic pregnancy can present with vaginal bleeding, patients with an IUD who develop an abrupt change in bleeding pattern and concomitant adnexal tenderness require evaluation.
UW. If transabdominal UG cannot locate the pregnancy, TVUG is performed because it is more sensitive and can better visualize the adnexa, particularly in obese patients or those with an early gestation.
.
UW. Endometrial biopsies are used to evaluate for endometrial hyperplasia/cancer in nonpregnant women with abnormal uterine bleeding. Although this patient has vaginal bleeding and obesity (a risk factor for endometrial hyperplasia), hyperplasia is unlikely in this patient with a progestin-containing IUD (protective against hyperplasia) and thin endometrium.
.
UW. FSH, TSH, and prolactin levels used to evaluate what?
abnormal uterine bleeding.
UW. IUD removal?
recommended for patients with an ultrasound-confirmed intrauterine pregnancy who wish to continue pregnancy.
This patient’s pregnancy should be located prior to offering IUD removal because an IUD can be left in place with no additional adverse effects if the pregnancy is extrauterine.
Mehl. ectopic definition?
Implantation of conceptus outside the uterus, including the parametrium of the uterus and cervix.
Mehl. b-hCG levels will be much…..???
lower than expected for gestational age
Mehl. b-hCG should double approximately every …..
2-3 days in early pregnancy, so the Q can also mention something about poor rate of change of increase.
Mehl. Highest yield point for USMLE is that ectopic risk is incr. (2 arrows up) in what Hx?
women who have Hx of PID.
this is due to scarring of the Fallopian tubes and disruption of the cilia.
Mehl. most common location of ectopic?
ampulla (70-80%).
Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic?
“small, stable ectopics” – i.e., mother is
hemodynamically stable, there is no evidence of tubal rupture / fluid in the peritoneal cavity, the ectopic is <3.5 cm, and b-hCG is <5000 mIU/mL.
Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic size?
<3.5 cm
Mehl. - Methotrexate is given for Tx (asked once on 2CK form) for what ectopic hCG levels?
b-hCG is <5000
Mehl. Laparoscopic salpingostomy/salpingectomy is done when?
if methotrexate cannot be given.
Mehl. IF HD unstable?
If the female is hemodynamically unstable (i.e., low BP), the answer is laparotomy, not laparoscopy.
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