ectopic pregnancy
TRANSCRIPT
Ectopic Pregnancy
Julio Espinosa, M.D.ALGIA
Pereira, Colombia
Ectopic Pregnancy
Diagnosis and Management of Ectopic Pregnancy
JOSHUA H. BARASH, MD; EDWARD M. BUCHANAN, MD; and CHRISTINA HILLSON, MD, Thomas Jefferson University,
Philadelphia, Pennsylvania Am Fam Physician. 2014 Jul 1;90(1):34-40.
Ectopic Pregnancy
• 1 – 2 % of all pregnancies• 9 % of pregnancy-related deaths in the US• 50 % reduction in mortality rates since 1980s
Risk Factors
• Conditions that damage the integrity of the tube and impair smooth muscle contractions and ciliary beating.
History
• Most common Sxs are 1st trimester bleeding and abdominal pain (unruptured)
• Clinical Hx should include:– Pregnancy dating – Onset and intensity of Sxs– Review of risk factors
Physical Therapy
• Assess for peritoneal signs:– Rebound & cervical motion tenderness (poss.
hemo-peritoneum)– Inspection of cervical os for POCs (Ectopic vs SAB)– Pathology (decidual cast vs POCs)
Imaging
• Trans-vaginal US• A GS containing a YS should be identified by
5.5 weeks GA• Hetero-topic pregnancy: 1 in 4000
spontaneous pregnancy• Diagnostic challenge: Pregnancy is not
identified
Laboratory Tests• B-hCG Discriminatory Level:– 1,500 – 2,000 IU/L– Not perfect: Viable IUP not detected by US reported
up to 4,300 IU/L.
• Serial B-hCG:– Most pregnancies (99 %) increase by 50 % in 48 hrs
• 1 % of viable IUP have slower rates of increase• 20 % of ectopics increase by 50 % in 48 hrs
– Monitor until undetectable. Ruptured ectopic have been documented at very low or falling B-hCG.
Laboratory Test
Laboratory Tests
• Blood Type and Rh status– Rh negative to receive Rh (D) immune globulin
(RhoGam)
Treatment
• Methotrexate vs. Open or Laparoscopic surgery vs. Expectant management.
• Medically unstable or hemorrhage Surgery• Choice should be based on patient preference• 2007 Cochrane review found no difference in
success rates between laparoscopic salpingostomy and medical treatment
Medical Treatment
• Cost effective & avoids risk of surgery and anesthesia
• Methotrexate:– Folic acid antagonist that inhibits DNA synthesis
and cell replication– Selectively kill cyto-trophoblasts (rapidly dividing
cells at the fallopian tube implantation site), body then resorbs.
Medical Treatment
• Patient selection is important• Predictors of treatment failure– GS larger than 3.5 cm– Presence of cardiac activity– Presence of blood in the peritoneum– High progesterone level– High initial B-hCG level• There is NO level at which medical management is
contraindicated!
Medical Treatment
Medical Treatment
• Contraindicated in those with immune system compromise, damage to organs that metabolize MTX, or conditions that could be exacerbated by treatment.
• CBC, Cr, LFTs needed!
Medical Treatment
• Regimens– Trials have involved single-dose, two-dose, and
multi-dose regimens. – Single Dose preferred
• Adverse Effects– GI effects• Rare:
– Severe neutropenia– Reversible alopecia– Pneumonitis
Clinical Recommendations
The End