PUL Flashcards
1
Q
•The most common final outcome among women diagnosed with PUL is ……..
A
spontaneous resolution of pregnancy without the need for treatment (50–70%)
2
Q
A serum hCG increase over 48 hours of more than….. (the hCG ratio >…) is a good predictor of an intrauterine pregnancy.
A
66%, 1.66
A decrease in hCG of >13% or a hCG ratio of <0.87 has been found to have a sensitivity of 92.7% and a specificity of 96.7% for the prediction of a failing PUL.
3
Q
What is the minimal rise to predict normal viable IUP ?
A
However, 15% of normal IUPs show a suboptimal increase and the minimum rise to predict normal viable IUP is 53%
4
Q
The chance of a repeat ectopic pregnancy in a woman with a history of one ectopic pregnancy is approximately
A
10%
5
Q
In a woman with two or more prior ectopic pregnancies, the risk of recurrence increases to more than
A
25%
6
Q
scar ectopic pregnancy incidence
A
occurred in 52 % of cases following prior one caesarean section, 36 % in prior two caesarean section and 12 % after three or more prior Caesarean section
7
Q
Methotrexate selection criteria:
A
included hemodynamically stable women with ß-hcg level of ≤5000 mIU/ml, adnexal mass ≤4 cm, absent cardiac activity and hemoperitoneum less than 100 ml.
8
Q
The success rate of single dose methotrexate therapy
A
was 65%
9
Q
what is percentage of tubal ectopic pregnancies? and each part from the most common to the least.
A
Nearly 95%, The ampulla (70 percent) is the most frequent site, followed by isthmic (12 percent),
fimbrial (11 percent), and interstitial tubal pregnancies (2 percent)
10
Q
The natural incidence of these heterotopic
pregnancies approximates
A
1 per 30,000 pregnancies, with assisted reproductive technologies (ART), their incidence is 9 in 10,000
pregnancies
11
Q
After one previous ectopic pregnancy, the chance of
another is increased ……fold
A
x five
12
Q
one episode of salpingitis can be followed by a subsequent ectopic pregnancy in up to … percent of women
A
9 percent of women
13
Q
Potential Outcomes of ectopic pregnancy
A
tubal rupture, tubal abortion, or
pregnancy failure with resolution.
hematosalpinx, rarely an aborted fetus will implant on a peritoneal surface and become an abdominal pregnancy
14
Q
chronic ectopic pregnancy B-hcg:
A
abnormal trophoblast dies early, and thus negative or
low, static serum β-hCG levels are found.
typically rupture late, if at all, but commonly form a complex pelvic mass, which often is the reason prompting diagnostic surgery.
15
Q
differential diagnosis for abdominal pain coexistent with pregnancy
A
Pain may derive from uterine conditions such as miscarriage, infection, degenerating or enlarging leiomyomas, or round-ligament pain. Adnexal disease
may include ectopic pregnancy; hemorrhagic, ruptured, or torsed ovarian masses; salpingitis; or tuboovarian abscess. Last, appendicitis, cystitis, renal stone, and
gastroenteritis are more common nongynecological sources of lower abdominal pain in early pregnancy.
16
Q
an intrauterine gestational sac is usually visible
A
between 4½and 5 weeks
17
Q
The yolk sac appears between
A
5 and 6 weeks
18
Q
a fetal pole with cardiac activity is first detected at
A
5½ to 6 weeks
19
Q
a trilaminar endometrial pattern can be
diagnostic for
A
ectopic pregnancy
(Its specificity is 94 percent, but with a sensitivity of only 38 percent)
20
Q
remember that
A
Anechoic fluid collections, which might normally suggest an early intrauterine gestational sac, may also be seen with ectopic pregnancy. These include pseudogestational sac and decidual cyst.
21
Q
a pseudosac is
A
a fluid collection between the endometrial layers and conforms to the cavity shape. If a pseudosac is noted, the risk of ectopic pregnancy is increased.
22
Q
a decidual cyst is identified as
A
an anechoic area lying within the endometrium but remote from the canal and often at the endometrialmyometrial border.
23
Q
The sonographic diagnosis of ectopic pregnancy (adnexal findings)
A
If fallopian tubes and ovaries are visualized and an extrauterine yolk sac, embryo, or fetus is identified, then an ectopic pregnancy is confirmed. In other cases, a hyperechoic halo or tubal ring surrounding an anechoic sac is seen.
24
Q
the single best prognostic indicator of successful treatment with single-dose MTX
A
initial serum β-hCG level.
reported failure rates are 1.5 percent if the initial serum β-hCG concentration is <1000 mIU/mL; 5.6 percent at 1000 to 2000 mIU/mL; 3.8 percent at 2000 to 5000
mIU/mL; and 14.3 percent when levels range between 5000 and 10,000 mIU/mL
25
ectopic pregnancy size and medical management:
93-percent success rate with single-dose MTX when the ectopic mass was <3.5 cm. This compared with success rates between 87 and 90 percent when the mass was >3.5 cm. Last, failure rates rise if cardiac activity is seen, with an 87-percent success
rate in such cases.
26
Criteria that may aid differentiation btw interstitial pregnancy and eccentric IUP include:
an empty uterus, a gestational sac seen separate from the endometrium and >1 cm away from the most lateral edge of the uterine
cavity, and a thin, <5-mm myometrial mantle surrounding the sac
27
CESAREAN SCAR PREGNANCY INCIDENCE
Its incidence approximates 1 in 2000 normal pregnancies and has increased along with the cesarean delivery rate
28
4 criteria for Caesarean scar pregnancy DX:
in CSP An empty uterine cavity is identified by a bright hyperechoic endometrial stripe.
An empty cervical canal is similarly identified.
Last, an intrauterine mass is seen in the anterior part of the uterine isthmus. Myometrium between the bladder and gestational sac is absent or thinned (1 to 3
mm).
29
potential long-term complication of caesarean section
Uterine arteriovenous malformations
30
CERVICAL PREGNANCY risk factors:
Predisposing risks include ART and prior uterine curettage
31
SONOGRAPHIC FINDINGS OF cervicoisthmic intrauterine pregnancy:
(1) an hourglass uterine shape and ballooned cervical canal; (2) gestational tissue at the level of the cervix.
(3) absent intrauterine gestational tissue; (4) a portion of the endocervical canal seen interposed between the gestation and the endometrial canal.
32
CLUE TO HELP IN DIAGNOSIS OF ABDOMINAL PREGNANCY:
maternal serum alpha-fetoprotein levels
can be elevated.
Clinically, abnormal fetal positions may be palpated, or the cervix is displaced
Sonographically, the diagnosis is often missed Oligohydramnios is common but nonspecific. Other clues include a fetus seen separate from the uterus or eccentrically positioned within the pelvis; lack of
myometrium between the fetus and the maternal anterior abdominal wall or bladder; extrauterine placental tissue; or bowel loops surrounding the gestational sac.
MR imaging can help confirm the diagnosis and provide maximal information concerning placental implantation
33
four clinical criteria for diagnosis of ectopic OVARIAN PREGNANCY:
(1) the ipsilateral tube is intact and distinct from the ovary; (2) the ectopic pregnancy occupies the ovary; (3) the ectopic pregnancy is connected by the uteroovarian ligament to the uterus; and (4) ovarian tissue can be demonstrated histologically amid the placental tissue.
34
What are the regimens for methotrexate?
1) a single dose protocol. 2) A two dose protocol 3) A fixed multiple dose protocol.
35
how HCG will be monitored after single dose protocol?
Day 1, day 4 and day 7.
36
How will you know that the patient is responding to the single dose protocol?
There should be 15% drop of HCG between day 4 and 7.
If does, Weekly HCG until its negative.
37
What If there was drop but less than 15%?
A second dose should be given with subsequent follow up of HCG on day 4 and 7. Up to 13% of patients will require a second dose.
38
how HCG will be monitored after fixed multiple doses protocol ?
On the days of each dose of methotrexate.
39
What is the success rate of methotrexate therapy in EP?
70-95%.
40
how should women be counseled regarding the treatment effects of methotrexate ?
Education regarding symptoms of tubal rupture. Avoid vigorous activity Avoid sexual intercourse Avoid folic acid supplements and NSAIDS Avoid narcotic analgesia , alcohol and gas producing foods to not mask the symptoms of tubal rupture. Avoid sunlight to limit the risk of methotrexate dermatitis Counsel regarding the potential of fetal death or teratogenicty. Avoid pregnancy for 3 months after therapy.
41
Who are the candidates for surgical management in ectopic pregnancy?
It’s necessary when a patient is exhibiting any of the following : 1) hemodynamics instability 2) Symptoms of an ongoing tubal rupture or signs of intraperitpneal bleeding. 3) Any contraindications to medical therapy.
42
who are the candidates for expectant management in ectopic pregnancy?
Should be Asymptomatic . Should have objective evidence of resolution ( manifested by a plateau or a decrease in HCG levels ) Must be counseled and willing to accept the potential risks which include tubal rupture , hemorrhage and emergency surgery.
43
what is the mortality rate of interstitial pregnancy ?
7 times the rate of ectopic pregnancy , most interstitial pregnancies are diagnosed at the time of rupture.
It's incidence 2-4% of all tubal pregnancies.
44
What are some of the symptoms of tubal rupture ?
Worsening abdominal pain , shoulder pain , syncope /dizziness.
45
What progesterone level predicts intrauterine pregnancy ?
>25 ng/mL suggests a normal pregnancy .
46
What is arias-Stella reaction ?
Arias-Stella reaction is due to progesterone primarily. Distinctive (usually focal) benign nuclear enlargement of "exaggerated hyperplastic" appearance characterized by centronuclear vacuolization, typically associated with pregnancy or hormone effect.
This finding may provide initial histologic "clue" of ectopic pregnancy!
47
What are the criteria for the diagnosis of ovarian pregnancy ?
1) the ipsilateral tube is intact and clearly separate from the ovary.
2) The gestational sac definitely occupies the normal portion of the ovary.
3) The sac is connected to the uterus by the utero-ovarian ligament.
4) Ovarian tissue is unquestionably demonstrated in the wall of the sac
48
What are the criteria for the diagnosis of cervical pregnancy ?
1) cervical glands must be opposite the placental attachment.
2) Placental attachment to the cervix must be situated below the entrance of the uterine vessels or below the peritoneal reflection of the anterior and posterior surfaces of the uterus.
3) Fetal elements must be absent from the corpus uteri.
Clinical criteria
1) uterine bleeding without cramping pain following a period of amenorrhea.
2) A soft , enlarged cervix equal to or larger than the fungus ( the “ hourglass “ uterus ).
3) Products of conception entirely confined within and firmly attached to the endocervix.
4) A closed internal os.
5) A partially opened external cervical os.
49
What are the criteria for the diagnosis of a cesarean scar pregnancy ?
1) visualization of an empty uterine cavity as well as an empty endocervical canal.
2) Detection of the placenta and/or a gestational sac embedded in the hystrotomy scar.
3) In early gestations ( <8 weeks ) a triangular gestational sac that fills the niche of the scar at >8 postmenstrual weeks , this sharpe may become rounded or even oval.
4) A thin ( 1-3 mm ) or absent myometrial layer between the gestational sac and the bladder.
5) A closed and empty cervical canal.
6) The present of a Byronic/fetal pole and/or yolk sac with or without heart activity.
7) The presence of prominent and at times rich vascular pattern at or in the area of cesarean delivery scar in the presence of a positive pregnancy test.
50
what is the treatment of cervical ectopic ?
Mostly surgical and the condition often required an abdominal hystrectomy. Medical therapy can also be considered for the primary treatment or in adjunct to surgical therapy. Skillful D&C in selected patients.
51
What is the treatment of cesarean scar pregnancy ?
Resection and uterine scar dehiscence repair by both laparotomy or laparoscopy approaches. Resection by hystroscopy or curettage has also occurred following bilateral UAE and systemic methotrexate.
52
IMP POINT: -
During laparoscopic salpingotomy, it is important to make the incision along the antimesentric wall of the tube in the area of maximal distension and large enough to allow for complete extrusion of the products of conception without difficulty. Following laparoscopic salpingotomy , healing by secondary intention is felt appropriate in most cases.
- all RH negative patients should be offered at least 50 microgram of Rh immunoglobulin .
-A D&C procedure is helpful when B-HCG and TVS are no diagnostic and a non viable pregnancy is suspected.
Appropriate indications include:
a) a failure of HCG to rise greater than 50% after 48 hours .
B) a serum progesterone level less than 5ng/ml.
C) a failure to visualize an intrauterine gestational sac by TVS , when B-HCG is above 1,500 IU/ L.
53
Spiegelberg criteria
four criteria used to identify ovarian ectopic pregnancies
The gestational sac is located in the region of the ovary.
The ectopic pregnancy is attached to the uterus by the ovarian ligament.
Ovarian tissue in the wall of the gestational sac is proved histologically.
The tube on the involved side is intact.
54
Pregnancy on Top of an IUD, what is the next step after counselling if strings still accessible?
Removal (decrease the chance of miscarriage from 50% to the normal rate of miscarriage)
55
Pregnancy on Top of an IUD, what is the next step after counselling if the strings not feasible
Don’t remove it
56
One of the factors that determines the Success of methotrexate in treating Ectopic pregnancy is B-hcg level prior, what the percentage of success of each:
- < 5000 Success rate 90%
- > 5000 - 10000 (85%)
- > 10000 (80%)
57
Rubin pathological criteria for the diagnosis of cervical ectopic pregnancy:
1) cervical glands must be present opposite the placental attachment,
2) the attachment of the placenta to the cervix must be intimate,
3) the whole or a portion of the placenta must be situated below the entrance of the uterine vessels, or below the peritoneal reflection of the anterior and posterior surface of the uterus
4) no fetal elements must be present in the corpus uteri.
58
US criteria to dx cervical ectopic pregnancy
1) an empty uterus, 2) a barrel-shaped cervix, 3) a gestational sac present below the level of the uterine arteries, 4) absence of the sliding sign (when pressure is applied to the cervix using the probe, the gestational sac slides against the endocervical canal in a miscarriage, but does not in an implanted cervical pregnancy) and 5) blood flow around the gestational sac on color Doppler
59
Risk factors for Ectopic pregnancy include (along with OR )
previous EP (odds ratio (OR) 8.3), tubal pathology (OR 3.5–25) and previous tubal surgery (OR 21).
60
one episode of salpingitis can be followed by a subsequent ectopic pregnancy in up to -- percent of women (Westrom, 1992). Peritubal adhesions that form from salpingitis, appendicitis, or endometriosis also raise chances
one episode of salpingitis can be followed by a subsequent ectopic pregnancy in up to 9 percent of women (Westrom, 1992). Peritubal adhesions that form from salpingitis, appendicitis, or endometriosis also raise chances
61
Potential Outcomes of tubal pregnancy
tubal rupture, tubal abortion, or pregnancy failure with resolution.
62
Methotrexate contraindications in ectopic pregnancy
ruptured fallopian tube, Immunodeficiency , MTX sensitivity, PUD, IUP, active pulmonary disease, breastfeeding, unavailability of reasonably close access to emergency care and a commitment to surveillance laboratory testing. MTX is renally cleared, and significant renal dysfunction, reflected by an elevated serum creatinine level, precludes its use. Second, MTX can be hepato- and myelotoxic, and CBC and liver function tests (LFTs) help establish a baseline. Last, blood type and Rh status are determined. All except blood typing are considered surveillance laboratory tests and are repeated prior to additional MTX doses.
63
With administration of methotrexate, women are counseled to avoid several aggravating agents until treatment is completed. These are:
(1) folic acid-containing supplements, which can competitively reduce MTX binding to dihydrofolate reductase; (2) nonsteroidal antiinflammatory drugs, which reduce renal blood flow and delay drug excretion; (3) alcohol, which can predispose to concurrent hepatic enzyme elevation; (4) sunlight, which can provoke MTXrelated dermatitis; and (5) sexual activity, which can rupture the ectopic pregnancy (American College of Obstetricians and Gynecologists, 2019c).
64
ectopic tubal pregnancy resolution rates approximate -- percent with MTX use
ectopic tubal pregnancy resolution rates approximate 90 percent with MTX use
65
classic predictors of success of medical treatment in ectopic pregnancy include
low initial serum β-hCG level, small ectopic pregnancy size, and absent fetal cardiac activity. Of these, initial serum β-hCG level is the best prognostic indicator with single-dose MTX. Reported failure rates are 1.5 percent if the initial serum β-hCG concentration is <1000 mIU/mL; 5.6 percent at 1000 to 2000 mIU/mL; 3.8 percent at 2000 to 5000 mIU/mL; and 14.3 percent for levels between 5000 and 10,000 mIU/mL (Menon, 2007). Many early trials also used large size as an exclusion criterion. Lipscomb and colleagues (1998) reported a 93-percent success rate with single-dose MTX when the ectopic mass was ≤3.5 cm. This compared with success rates between 87 and 90 percent when the mass was >3.5 cm. These authors also found ectopic pregnancies measuring ≤4 cm and lacking cardiac activity to be suitable candidates. Failure rates rise if cardiac activity is seen, with an 87-percent success rate in such cases.
66
The most frequent side effect of methotrexate in ectopic pregnancy were
liver involvement—12 percent; stomatitis—6 percent; and gastroenteritis—1 percent. 65 to 75 percent of women given MTX will have increasing pain beginning several days after therapy. Thought to reflect separation of the ectopic pregnancy from the tubal wall, this pain generally is mild and relieved by analgesics.
67
After single-dose MTX, mean serum β-hCG levels may rise or fall during the first 4 days and then should gradually decline. If the level fails to drop by ≥15 percent between days 4 and 7.
Next step
a second MTX dose is recommended. This is necessary in 20 percent of women treated with single-dose therapy (Cohen, 2014). In such cases, a CBC, creatinine level, and LFTs are rechecked. If these surveillance tests are normal, a second equivalent dose is administered. The date of this second injection will become the new day 1, and the protocol is restarted.
68
How is the Surveillance of Multidose therapy in ectopic pregnancy MTX (1 mg/kg) treatment with leucovorin (0.1 mg/kg) therapy on alternating days.
After this first pair of injections, a serum β-hCG concentration is obtained. Values between days 1 and 3 are anticipated to drop by ≥15 percent. If not and if surveillance tests are normal, an additional MTX/leucovorin pair is given. A serum β-hCG level is repeated 2 days later. Up to four doses may be given if required
69
In expectant management of ectopic pregnancy Predictive factors for success include a low initial serum β-hCG concentration, a significant drop in levels over 48 hours, and a sonographic inhomogeneous mass rather than a tubal halo or other gestational structures.
initial values <175 mIU/mL predict spontaneous resolution in -- to -- percent of attempts while Initial values <1000 mIU/mL have success rates ranging from -- to -- percent
initial values <175 mIU/mL predict spontaneous resolution in 88 to 96 percent of attempts while Initial values <1000 mIU/mL have success rates ranging from 71 to 92 percent
70
In interstitial pregnancy Risk factors are similar to others discussed for tubal ectopic pregnancy, although (which rusk factor) is a specific one for interstitial pregnancy
previous ipsilateral salpingectomy
71
Interstitial pregnancies sonographically can appear similar to an eccentrically implanted IUP, especially in a uterus with a müllerian anomaly. Criteria that may aid differentiation include:
an empty uterus, a gestational sac seen separate from the endometrium and >1 cm away from the most lateral edge of the uterine cavity, and a thin, <5-mm myometrial mantle surrounding the sac , an echogenic line, known as the interstitial line sign, extending from the gestational sac to the endometrial cavity most likely represents the interstitial portion of the fallopian tube and is highly sensitive and specific. In unclear cases, three-dimensional (3-D) sonography, magnetic resonance (MR) imaging, or diagnostic laparoscopy can help clarify anatomy. Laparoscopically, a myometrial protuberance is seen to lie lateral to the round ligament and coexists with normal distal tubes and ovaries.
72
Cesarean scar pregnancy vs. IUP vs. spontaneous expelling abortus
Sonographically, differentiating between an IUP implanted at the cervicoisthmic junction and a CSP can be difficult. Investigators in one study marked the midpoint of the uterine length (cervix to fundus) in sagittal views. If the center of the gestational sac lay distal to this midpoint, a CSP was diagnosed (Timor-Tritsch, 2016). A spontaneous expelling abortus is another mimic. Color Doppler will show the intense placental vascularity around a CSP, whereas as the aborting sac is avascular. Moreover, gentle pressure applied to the cervix by the vaginal probe will fail to move an implanted gestation—a negative sliding sign. Instead, an aborted sac will slide against the endocervical canal (Jurkovic, 2003). TVS is the typical first-line imaging tool, but MR imaging is useful for inconclusive cases
73
From one literature review, the most successful operations in cesarean scar pregnancy management include:
(1) laparoscopic uterine isthmic resection; (2) transvaginal isthmic resection through an anterior colpotomy, created similarly to anterior entry during vaginal hysterectomy; (3) UAE, followed by D & C with or without hysteroscopy; and (4) hysteroscopic resection (Birch Petersen, 2016; Wang, 2014). The Society for Maternal-Fetal Medicine (SMFM) (2020) considers sonography-guided vacuum aspiration alone, but not sharp curettage, to be suitable. In some instances, hysterectomy is required or may be elected in those not desiring future fertility.
74
success rate of Local/ systemic plus local MTX in cesarean scar pregnancy management (percentage)
Local MTX injection into the gestational sac alone provided a success rate of 60 percent, and systemic plus local MTX raised the rate to nearly 80 percent (Maheux-Lacroix, 2017). The SMFM (2020) recommends against systemic MTX alone.
75
CERVICAL PREGNANCY defined first by
cervical glands noted histologically opposite the placental attachment site. Second, all or part of the placenta lies at a level below the entrance of the uterine vessels or below the peritoneal reflection on the anterior uterus. Trophoblast invades the endocervix, and the pregnancy develops in the fibrous cervical wall.
76
CERVICAL PREGNANCY Risk factors include
ART and prior uterine curettage
77
Cervical pregnancy management
Cervical pregnancy may be treated medically or surgically. MTX is first-line therapy in hemodynamically stable women. Of options, single- or multidose systemic MTX and dosing. Alternatively, 50 mg of MTX can be injected directly into the gestational sac or chemoembolization with MTX and UAE.
78
four clinical criteria of ovarian ectopic pregnancy
(1) the ipsilateral tube is intact and distinct from the ovary; (2) the ectopic pregnancy occupies the ovary; (3) the ectopic pregnancy is connected by the uteroovarian ligament to the uterus; and (4) ovarian tissue can be demonstrated histologically amid the placental tissue.
79
HETEROTOPIC PREGNANCY This pairing of an IUP and an ectopically located pregnancy is rare, and the most common dyad is
an IUP and an ampullary tubal pregnancy.
80
the most frequent cause of heart failure in pregnancy
