PUL/ectopic pregnancy Flashcards
what is discriminatory zone
3500 - should see IUP (99% seen on US)
multiple gestations typically have higher thresholds
HCG in 48 hours
- should increase 35% if IUP
- 21% ectopics also increase by 35% and up
- should decrease 36-47% if nonviable IUP
- 8% ectopics also decrease by this much
70% ectopics fall <35% rise and less than 36% decline
if unclear diagnosis after 48 hours, when to check HCG again?
2-7 days
normal US findings of viable IUP
- gestational sac 4.5 - 5 weeks
- yolk sac 5-6 weeks
- fetal pole with cardiac activity 5.5-6 weeks
definitive signs of non-viable IUP
- CRL 7mm or greater with no heart beat
- MSD 25 mm or greater with no embryo
- Absence of embryo 2 weeks or more after GS seen without YS
- Absence of embryo with heart beat 11 days or more after GS with yolk sac seen
If viable IUP excluded, and first step D&C. Expected HCG trends/managment…
Check HCG In 12-24 hours.
- If 50% and greater decrease, then serially monitor HCG. Likely this was nonviable IUP.
- If less than 50%, then offer tx for presumed ectopic or monitor serial HCGs with close precuations
absolute contraindications to MTX
- IUP
- clinically important liver disease
- clinically important renal disease
- moderate to severe anemia, thrombocytopenia, leukopenia
- active pulmonary disease
- active peptic ulcer disease
- breast feeding
- ruptured ectopic pregnancy
- hemodynamic instability
- sensitivity to MTX
relative contra-indications to MTX
- embryonic cardiac activity visualized by TVUS
- high (> 5000 ) initial HCG levels
- greater than 4 cm ectopic pregnancy by size
- refusal to accept blood transusion
What are MTX dosing regimens called - what are benefits/when would you use each.
- single dose. (Additional dose needed in 25% of patients)
- two-dose (may be better for women with higher initial HCG levels, faster resolution of HCG)
- fixed multiple dose
no difference in regimens with regards to resolution of ectopic without need for surgery
details of single dose
- 50 mg/m^2 on day 1
- measure HCG on day 4 and day 7
- if decrease greater than 15% from D4 to D7, check HCG weekly until it reaches nonpregant level
- if less than 15% decrease, readminister 50 mg/m^2, readminister dose.
- consider surgery after 2 doses
- if increasing/plateu during follow-up consider adminsitering another dose of MTX for persistent ectopic pregnancy
details of 2-dose regimen
- 50 mg/m^2 on day 1
- 50 mg/m^2 on day 4, measure HCG
- measure day 7 HCG
- if D4 -> D7 decrease greater than 15%, then weekly HCG until negative
- if D4 ->7 less than 15% decrease, then another 50 mg/m^2 on day 7
- check day 11 HCG
- if less than 15% decrease from day 7 -> day 11, then another 50 mg^2 dose on day 11.
- check day 14 hcg
- if day 11 -> day 14 still less than 15% decrease, then consider surgery. (i.e. no further try after 4 doses)
details of fixed multiple dose regimens
- MTX 1 mg/kg IM on days 1, 3, 5, 7
- Folinic acid mg/kg IM days 2, 4, 6, 8
- measure HCG on MTX days
- if greater than 15% decrease, then stop MTX and get weekly HCG until negative
- if less than 15% decrease, continue until max of 4 doses given
side effects of MTX
- most common: nausea, vomiting, stomatitis
- vaginal spotting expected
- 2-3 days post tx, cytotoxic effect of drug on trophoblastic tissue -> abdominal pain. in absence of peritoneal signs, radiographic rupture/hemoperitoneum, hemodynamic instability -> observe
- alopecia, leukopenia, thorombocytopenia, transaminitis rare
do’s/don’ts for women on MTX
- no folic acid supplements
- no NSAIDs (interferes with efficacy of MTX)
- avoid sunlight (MTX dermatitis)
- avoid vigorous activity, sex
- talk about teratogenic effect; expert opinion recommends waiting 3 mo before conceiving
absolute indications for surgery
- hemodynamic instability
- symptoms of ongoing rupture ectopic mass
- intraperitoneal bleeding
