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
salpingectomy vs salpingostomy
- in randomized trials, equal future fertility rates
- if contralateral tube damaged, consider salpingostomy b/c otherwise needs ART
- if salpingostomy, f/u with HCGs serially
medical vs surgical
Generally surgical more effective in resolution than MTX. Comparable future fertility and ectopic pregnancy rates. Risks of surgery etc.
Bottom line there are comparable
criteria for expectant management of ectopic pregnancy
- asymptomatic
- objective evidence of resolution
- willing to accept risks
88% will spontaneously resolve if hcg <200
cervical ectopic
- TVUS/exam findings
- DDx
- TVUS: empty uterus, gestational sac within cervical canal, doppler flow to peritrophoblastic tissue, absent sliding sign (sac does not slide along cervical canal with gentle pressure)
- exam: enlarged barrel shaped cervix; bigger than uterus. avoid BME if suspecting cervical ectopic
- incomplete AB, c-section scar/hysterotomy scar ectopic
c-section scar ectopic
can try MTX, although cure rates not as reliable.
- surgery: hysterectomy, isthmic resection (laparoscopically, transvaginally, UAE followed by D&C, hysteroscopically
ovarian ectopci
managed surgically. small ectopics can be managed with wedge resections, larger with oophorectomy
Time to wait to conceive after mtx?
Expert rec 3 months. Limb and cranial abnormalities.
