7/29/2019 Print - Ectopic Pregnancy - 10min Talk

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ECTOPIC PREGNANCYEpid. MC site = fallopian tubes,specifically the ampulla

Site w/ greatest risk of rupture = intramural portion of fallopian tubes (Cornual Pregnancy) Ectopic Pregnancy is the MCC of pregnancy-related maternal death in T1. incidence (~1:1000) may be 2 to in assisted fertility, STIs, & PID. More common in women >35YO

RF Previous ectopic pregnancy (#1 MC risk factor) History of tubal surgery (7:1,000 for tubal ligation) PID, endometritis, or current gonorrhea/chlamydia infection Pelvic adhesive disease (infection, prior surgery) Use of an IUD (absoluterisk of ectopic preg. overall, but risk of pregnancy being ectopic if pregnancy occurs) Use of assisted reproductive technologies (e.g., IVF, embryo transfer) DES exposure in utero Cigarette smoking Disorders that affect ciliary motility may be at increased risk.

H&P VB Tender adnexal mass Pelvic pain, unilateral Sx of Rupture

-hypotension-tachycardia-abdominal rebound tenderness (2 to hemoperitoneum)

*Always check a pregnancy test on all reproductive age women with abdominal pain and/or VBDDx Threatened Abortion

Ovarian Torsion PID Acute appendicitis Ruptured Ovarian Cyst Tubo-ovarian Abscess Degenerating Uterine Leiomyoma

Dx URINE PREGNANCY TEST (UPT) will be positive 1wk after conception when -hCG>25 QUANTITATIVE SERUM -hCG

--hCG should by 66% every 48hrs in first 7wks of gestation after day 9. If rise is less, suspect ectopic.--hCG of 1500-2000: IUP detectable w/ TVUS. If no evidence of IUP, suspect ectopic.--hCG of 5000: IUP detectable w/ abdominal US; fetal heartbeat seen.-* -hCG levelsdo notcorrelate with: size of ectopic, potential for rupture, location of ectopic, GA of ectopic.

PROGESTERONE normal IUP if >25; Abnormal (ectopic or nonviable) if

STABILIZE: IV fluids, blood products, pressors EXPLORATORY LAPARTOMY(if hemo. unstable)

- Stop bleeding and remove ectopic by makinglarge incision on abdominal wall.

LAPAROSCOPY(if stable) small incision SALPINGECTOMY

-Removing the fallopian tube, (complete vs. partial)-*Partial Salpingectomy:risk of future ectopic preg

SALPINGOSTOMY-Removal of ectopic preg, but leaves the tubes intact-Incision on the antimesenteric portion of the tube-Follow -hCG down to zero to ensure complete

removal of ectopic tissue.

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SALPINGOSTOMY METHOTREXATE (MTX)

-Indications:(1) Hemodynamically stable, (2) Size < 3.5cm,

(3) Px compliant for f/u (4) IUP has been r/o

-Relative Contraindications:(1) fetal cardiac activity of ectopic preg., (2) -hCG>15,000, (3) Size >3.5cm

-Absolute Contraindications:(1) hemo. Unstable, (2) WBC/platelets,

(3) Liver/Renal Dz, (4) PUD, (5) concurrent viableIUP, (6) Ruptured ectopic, (7) Breast-feeding

-Monitor: (1) baseline transaminases, (2) Creatinine,(3) serial -hCG, (4) S/Sx of rupture

-* Donotcoadminister NSAID+MTXnephrotoxicity

7/29/2019 Print - Ectopic Pregnancy - 10min Talk

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Is Pt acutely symptomatic:hypotension, volume

depleted, severe abd/pelvicpain or adnexal mass?

Consder laparoscopyor laparotomy

Quantitiatve serumhCG

hCG < 1500-2000

Serial hCG every 48hr U/S

Normal Rise (>66%)

ViableIUP

Repeat sono whenhCG exceeds

threshold

Abnormal Rise

NonviablePregnancy

UterineCurettage

Path: Chorionic Villi Path: No Villi

Ectopic

Consider MTX

Miscarriage(e.g. Threatened

Abortion)

hCG>1500-2000

Transvaginal U/S

IUP Seen No IUP Seen

ConsiderLaparoscopy

Observe

YES NO