Flashcards in Clinical: Ectopic Preggers Deck (38):
Define Ectopic Pregs.
A Gestation that Implants Outside the Endometrial Cavity.
Why is ectopic pregnancy important to find and treat early ?
the fourth leading cause of maternal mortality overall.
It is the leading cause of maternal mortality in the first trimester.
Why has ectopic pregnancy quadrupled in since 1970's ?
Increase in Pelvic Inflammatory Disease (Rates increase 6-10x)
What pathogen is most often associated with Pelvic Inflammatory Disease and has had a role in the increase of Ectopic Pregnancy ?
What is the most important risk factor for EP ?
Prior PID (Prior EP is also highly correlated)
What mechanical etiologies can lead to EP ?
Previous Tubal Surgery
History of Infertility and Reproductive Therapy
IUD (not so much any more)
What is the most common site of EP ?
Uterine Tube (Ampulla is most common site )
When will most ectopic pregnancies present to you in clinic ? Why ?
Most EP's are in the uterine tube. By 7 weeks the growth in the tube leads to immense pain and possible rupture --> Doctors visit !
Classic Triad of Ectopic Pregnancy:
1. Abdominal/Pelvic Pain (90%)
2.Vaginal Bleeding (50-80%)
3. Amenorrhea (75-90%)
Typically patients present with abdominal pain and distension as well as symptoms of hypovolemia. What are the symptoms of hypovolemia ?
Tachycardia, Diaphoresis,Orthostatic Blood Pressure Changes.
Will most patients with EP present with fever ?
No most are afebrile
What percentage of patients with EP will present with an adnexal mass ?
50% (kind of a crap shoot)
In half of these the mass is contralateral
and represents the corpus luteum.
In all patients in which you think there might be an EP, you have to assume ..
What 3 modalities are used to diagnose EP
What level of hCG must be present to confirm a 'viable' pregnancy ?
1200 (although the other prof said 1500)
In the early stages of pregnancy, what would you like to see the hCG levels do every 48 hrs to quantify a good prognosis for viability of the pregnancy ?
What is ultrasound used for in the diagnosis of EP ?
looking for presence or absence of uterine pregnancy
Preferably endovaginal which can detect pregnancy post 5 weeks gestation.
You may be able to see an ectopic pregnancy on US as well
What level of progesterone is indicative of Inter Uterine Pregnancy ?
Suppose you obtain a hCG of 1000 and a negative ultrasound done at 5 weeks. Is this enough to diagnose an ectopic pregnancy ?
Even though there is no sign on pregnancy on US you will still need a level of hCG greater than 1200 to definitively diagnose an EP
What is Culdocentesis ?
Put a needle through the culdesac (pouch of douglas).If blood clots its vascular, if not its probably ectopic).
Not used much
What is the GOLD STANDARD for EP diagnosis ?
hCG and Endovaginal US
What minimally invasive procedure can you use to diagnose an EP ?
What medical EP treatment utilizes the blocking of Dihydrofolate Reductase leading to inhibition of pregnancy progression ?
Methotrexate (Folinic Acid Antagonist)
For which patients is methotrexate indicated ?
No Fetal Cardiac Motion
Patient Desires Future Fertility
What are some common contraindications to methotrexate use ?
What is methotrexate dosing based on ?
Surface area (50 mg/m^20
How do you monitor to see if methotrexate has worked in limiting EP ?
Serial S- hCG . Should eventually lower to zero
(hCG will increase in the first 4 days but should begin to decline by day 7)
What should you do if initial methotrexate dosing fails ?
Give a second dose or consider surgery
Using a scope to with a small incision to visualize target (in this case a tubal EP)
Use of a much larger incision than laproscopy (often thought of as exploratory surgery)
Creating a cut in the fallopian tube and then excising the contents while leaving the fallopian tube intact. You do not close this with sutures as the healing process will harm the tube
Removal of the fallopian tube with tubal ligation
Can be total or subtotal.
Will require ligating with either suture or cauterization
What should you treat Rh- mothers with prior to EP surgical removal ?
What should be done post surgery to monitor effectiveness of treatment ?
Serial S-hCG levels
What must you consult after the procedure to be sure of diagnosis and prospected outcome ?
What should patients avoid for 3-6 months post EP removal ?
The damage to the tube could lead to another EP
Relative future risk if there is a history of EP ?