ectopic pregnancy - loyola university chicago
TRANSCRIPT
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Ectopic PregnancyRecia Frenn, MD MA
April 2020
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Outline
Definitions & Statistics
Diagnosis
Medical and Surgical Treatment
Surgical Videos
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Ectopic pregnancy
stats
Incidence: 1-2% of all pregnancies
~10% of all women presenting to ED with 1st trimester c/o
3 % of all pregnancy-related death
Leading cause of hemorrhage related mortality
Heterotopic (rising with ART. Used to be 1:30,000. Now
1:4,000)
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Risk factors
previous ectopic
previous tubal surgery or tubal ligation
h/o STIs/PID
Current IUD
Infertility
Smoking
Previous pelvic surgery
Endometriosis
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Clinical manifestations
First trimester vaginal bleeding and pelvic pain
Asymptomatic
Lower likelihood of pregnancy symptoms (breast
tenderness, nausea)
Typically 6-8 weeks after LMP
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Evaluation for suspected
ectopic pregnancy
confirm patient is pregnant
determine whether pregnancy is intrauterine or ectopic
determine whether ectopic has ruptured and if patient
hemodynamically stable
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History
LMP
Characteristics of bleeding and pain
Identify risk factors for ectopic
General health history
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Physical
Vital signs/assess hemodynamic stability
Abdominal/pelvic exam
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Initial diagnostic testing
HCG
Ultrasound
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HCG
Discriminatory zone: HCG above which a gestational
sac should be visualized by TVUS.
HCG 1500-2000, most IUPs are seen on TVUS
HCG of 3500 for 99% of IUPs
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Ultrasound
TVUS excludes ectopic if: IUP seen (gestational sac
with yolk sac or fetal pole). Gestational sac alone
insufficient as could be pseudosac.
TVUS confirms ectopic if: gestational sac with YS/FP
seen outside the uterus
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Natural history
Spontaneous resolution
Tubal abortion
Tubal rupture
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Treatment
Medical (Methotrexate)
Surgical (Salpingectomy or Salpingostomy)
(Expectant Management)
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Surgical indications
Hemodynamically unstable patient
Signs/symptoms of impending or ongoing rupture
Failed medical therapy
Desire for sterilization
Planned IVF with known hydrosalpinx
Patient preference***
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Methotrexate
~1/3 are candidates
Optimal candidates: HD stable, willing and able to
comply with follow up, HCG<5000, Ectopic mass <3.5
cm, no fetal cardiac activity.
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Methotrexate-
Pharmacology
Folic acid antagonist
Otherwise used for neoplasia, severe psoriasis, and
rheumatoid arthritis
Inhibits DNA synthesis and cell reproduction, primary
in actively proliferating cells
Renally cleared
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Contraindications to MTX
Immunodeficiency
Active pulmonary disease
Peptic ulcer disease
Breastfeeding
Heterotopic (with co-existing viable IUP)
Allergy to MTX
Clinically significant abnormalities in baseline hematologic, renal or hepatic lab
values
Not able to comply with post-treatment follow up, lack of timely access to hospital
for management of tubal rupture
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Surgical treatment
Salpingectomy
Salpingostomy
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Surgical management
Laparoscopy vs
Laparatomy
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Post-op monitoring
Follow HCG down to undetectable
Rhogam
Recurrence risk counseling
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Interstitial Pregnancy (Video)
Ruptured Ectopic (Video)
https://www.youtube.com/watc
h?v=-qIt4RqHk_I&t=25s
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https://www.youtube.com/watc
h?v=f7uzm6sg04U