Ectopic Pregnancy

Question 1

Ectopic Diagnosis

Answer 1

HCG Rise 53% in 48 hours
Discriminatory Zone 1500
-Don’t use for IVF or ovulation induction

Date of pregnancy Discriminatory zone 38 days after menses

Question 2

Miscarriage

Answer 2

Gest sac of 25 mm without yolk sac or
fetal pole confirms anembryonic
pregnancy (blighted ovum)

CRL of 7 mm without FHM confirms
embryonic demise (missed Ab)

Question 3

Methotrexate

Answer 3

Antimetabolite, interrupts
synthesis of purine nucleotides
(folic acid antagonist)
• Metabolized in the kidney

Question 4

Who can use Methotrexate?

Answer 4

Hemodynamically stable
• With no signs of ruptured adnexal
mass
• Able to comply with follow-up care
- desires fertility
- coexisting IUP
• Without contraindications to MTX

Absolute contraindications:

1. Breastfeeding
2. Evidence of immunodeficiency
3. Alcoholism, liver disease
4. Pre-existing blood dyscrasias or anemia
5. Hepatic, renal or hematologic dysfunction
6. Active pulmonary disease, or peptic ulcer
7. Known sensitivity to MTX

Relative contraindications:

1. Gestational sac  3.5 cm-4 cm
2. Fetal cardiac motion
3. HCG>5000

Question 5

Baseline Testing prior to MTX and Patient instructions

Answer 5

• Baseline tests:
- CBC, LFTs, creatinine, Rh

• Patient instruction:
1. No coitus or strenuous exercise
2. No folic acid intake (i.e. vitamins)
3. Warn Patient: Poss. rupture  need of
surgery
4. acetaminophen for pain

Question 6

Side effects of MTX

Answer 6

Nausea, vomiting, stomatitis,
GI symptoms, dizziness, pneumonitis
(Rarely alopecia or neutropenia, elevated transaminase)

Question 7

MTX Regimen

Answer 7

Single dose: 50 mg/m2 IM on day 1

Fixed multidose;
1mg/kg IM on day s 1,3,5,7 alternating with folinic acid 0.1
mg/kg IM on days 2,4,6,8

Check ß-hCG on days 4 and 7:  > 15%
• If  < 15%, consider a repeat MTX dose
• ß-hCG weekly till it falls to non-pregnant level
(< 5-10 mIU/ml)

Question 8

Who is at risk for MTX failure

Answer 8

Gestational age, higher pre-Rx hCG ; P4 levels,
and (+) fetal heart motion
• Previous ectopic pregnancy regardless of type of
Rx: 20% failure vs. 7% in first-time EP

Question 9

Persistent Ectopic Pregnancy

Answer 9

Definition: Persistent hCG levels ± symptoms
following conservative therapy
• Prevalence: 3 - 20% after salpingostomy
4 - 6% after MTX Rx
Follow BHCG until negative

Question 10

Cervical Ectopic

Answer 10

Treatment Options:
 Multi-dose MTX (with folinic acid rescue)
Direct MTX injection
 Surgical Rx:
D&E with large Foley balloon
Hysterectomy
Uterine artery ligation
 Uterine Artery embolization

Question 11

ovarian pregnancy

Answer 11

Will need surgery MTX is ineffective