OBAb: Ectopic Pregnancy

Question 1

97% of ectopic pregnancy occur in the fallopian tube. In the fallopian tube, what is the most common location of ectopic pregnancy?

Answer 1

81% ampullary

12% isthmic - most tubal rupture occurs within the first few weeks

Question 2

Classic triad of ectopic pregnancy

Answer 2

1. Delayed menstruation
2. Pain
3. Vaginal bleeding or spotting

Question 3

What is the discriminatory b-HCG level in patients with ectopic pregnancy?

Answer 3

1500 mIU/mL

Question 4

What is the serum progesterone cut-off value for patients with ectopic pregnancy?

Answer 4

10-25 ng/mL

Question 5

A patient came in with (+)HCG, no uterine pregnancy, fluid in the cul-de-sac, and trilaminar pattern on TV-UTZ. What is your diagnosis?

Answer 5

Ectopic pregnancy

Question 6

___ is a surgical intervention where a linear incision at the antimesenteric border which is then left unsutured to heal by secondary intention

Answer 6

SalpingoStomy

SalpinGOtomy - if sutured

Question 7

___ is the single best prognostic indicator of successful treatment using one dose of MTX

Answer 7

Initial B-HCG

<10,000 mIU/mL - 14% failure rate
<1000 mIU/mL - 1.5% failure rate

Question 8

Contraindications of using methotrexate as treatment for ectopic pregnancy

Answer 8

1. Abdominal hemorrhage
2. Intrauterine pregnancy
3. Breastfeeding
4. Immunodeficiency
5. Chronic renal disease
6. Chronic hepatic disease
7. Chronic pulmonary disease
8. Blood dyscrasia
9. Peptic ulcer disease

Question 9

Size of ectopic pregnancy which has a 87-90% success rate once treated with MTX

Answer 9

Size more than 3.5cm

If less than 3.5, 93% success rate

Question 10

Cite the criteria for medical management of ectopic pregnancy

Answer 10

1. Stable patient
2. Beta HCG < 1500
3. < 3.5cm
4. <6 weeks AOG
5. No FHT

Question 11

Cite the MTX regimen for ectopic pregnancy

Answer 11

1. Single dose MTX 50mg/m2, IM
2. Two doses: MTX 50mg/m2, IM of Day 1 and 4
3. Multiple doses: MTX 10mg/m2, IM on days 1,3,5,7
   then Leucovorin 1mg/kg on days 2, 4,6,8

Question 12

When to stop MTX treamtment? (Cut off bHCG)

Answer 12

If there is a more than 15% decrease from initial level.

Question 13

Criteria for expectant management fo ectopic pregnancy

Answer 13

1. Tubal pregnancy only
2. Low serum b-hcg
3. diameter of ectopic mass is NOT more than 3.5cm
4. no intraabdominal bleeding or rupture

Question 14

Percent drop in the conception rate of the first pregnancy is an ectopic pregnancy

Answer 14

35%

Generally, 60% drop in conception rate. If up to G4 patient had ectopic pregnancy, the conception ratedrops to 80%

Question 15

what are the indications for methotrexate therapy?

Answer 15

1. Pregnancy <6 weeks
2. Tubal mass <3.5
3. No cardiac activity
4. Serum beta hCG <10-15,000 mIU/mL

Question 16

[Medical treatment]

Cite the single dose regimen, when to monitor beta hCG, and indication for additional dose

Answer 16

1. Methotrexate 50mg/m2 BSA

bhCG on days 1, 4, 7

Add dose if

1. bHCG does not decline by 15% from day 4 to 7
2. Less than 15% decline during weekly surveillance

Question 17

[Medical treatment]

Cite the miltidose regimen, when to monitor beta hCG, and indication for additional dose

Answer 17

1. Methotrexate 1mg/kg days 1,3,5,7
2. Leucovorin days 2,4,6,8

bCG on days 1,3,5,7

Add dose if:

1. serum b-hCG declines <15%, repeat bhCG after 48 hours; max 4 doses

Question 18

What are the contraindications to methotrexate?

Answer 18

1. Sensitivity
2. Tubal rupture
3. Breastfeeding
4. Intrauterine pregnancy
5. Hepatic, renal, hematological
6. PUD
7. Active pulmonary disease
8. Evidence of immunodeficiency