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28 Cards in this Set
- Front
- Back
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Define ectopic pregnancy
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Non-endometrial blastocyst implantation
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a) What is the incidence of ectopic pregnancy in an unselected patient population?
b) What is the mortality rate now? |
a) 1-2% of all pregnancies
b) 1/2000 ectopic pregnancies (0.05%) Ectopic pregnancy accounts for 5-10% of all pregnancy-related deaths |
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What is the most common site for ectopic pregnancy?
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Fallopian tube (95%)
Ampulla (70%) Isthmic (12%) Fimbrial (11%) |
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List some factors suggested to be responsible for the increasing incidence of ectopic pregnancy
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Better detection
More STIs (e.g. Chlamydia) Tubal factor infertility (reversal) Late maternal age IUDs and tubal clipping |
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True or False: In the United States, mortality from ectopic pregnancy has consistently been higher for non-white women.
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True (4-5X)
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a) What is the most significant risk factor for ectopic pregnancy?
b) List other risk factors |
a) Previous ectopic pregnancy (OR 12.5)
b) Prior tubal surgery (OR 4.0) Smoking > 20 cig / day (OR 3.5) Prior STI w/ confirmed PID or Chlamydia (OR 3.5) >=3 spontaneous abortions (OR 3.0) In Utero DES exposure Age >= 40a Prior TA (med or surg) Infertility > 1yr IUD (OR 1.3) |
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What is the pregnancy rate and ectopic rate for women with a Mirena IUD?
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0.5% - 50% will be ectopic
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What contraceptive method is associated with the highest relative-risk of ectopic pregnancy?
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Mirena (50% of pregnancies will be ectopic)
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Does IVF increase the chance for ectopic pregnancy above 1-2% baseline risk?
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Not appreciably.
(2% risk of ectopic with IVF) Increased relative-risk of cervical, interstitial, and heterotopic pregnancy |
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Name two tubal pathologies that predispose to tubal ectopic pregnancy
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Chronic Salpingitis
Salpingitis isthmica nodosa |
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What is the incidence of heterotopic pregnancy in:
a) spontaneously conceived pregnancies b) pregnancy by ART |
a) 1/30000 pregnancies
b) ~1% |
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a) What is the most common presenting complaint given by women who are diagnosed with ectopic pregnancy?
b) What is the classic "triad"? |
a) Abdomino-pelvic pain
b) Pain Amenorrhea Vaginal bleeding |
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When considering the diagnosis of ectopic pregnancy, what is the 'discriminatory zone'?
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Quantitated level of bhCG above which an intrauterine pregnancy, if present, should be visible on transvaginal U/S.
Can by 1000-2000 mIU/ml |
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What are the diagnostic possibilities in a women with a positive bhCG and no evidence of intrauterine gestation?
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Ectopic pregnancy - growing or aborting
Spontaneous abortion Early intrauterine pregnancy [the corpus luteum, solid or ruptured can appear as a complex adnexal mass and confuse the diagnosis.] |
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a) What is the earliest ultrasound finding specific for diagnosing an intrauterine gestation? Describe this finding.
b) What is a pseudosac? |
Gestational Sac - anechoic fluid collection surrounding by an echogenic ring.
b) collection of fluid/sloughed decidua that can resemble a gestational sac. Usually it is less round and more oval. |
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What is the typical rate of rise of bhCG in a normal pregnancy in the first 6 weeks?
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66% increase q48h
53% is lowest recorded ever for a normal pregnancy bhCG continues to rise in this pattern until 6 wks GA |
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Besides bhCG and TVUS, are any other tests useful in the diagnosis of ectopic pregnancy?
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Curettage
may reduce by 30% the number of women getting methotrexate for miscarriage misdiagnosed as ectopic) Serum Progesterone a low number may help distinguish between a viable and non-viable pregnancy Inhibin A, VEGF novel markers that may be used in the future |
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List some contraindications to the use of methotrexate therapy for ectopic pregnancy.
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Hemodynamically unstable
Signs of impending or ongoing ectopic mass rupture - severe or persistent abdominal pain - >300 mL of free peritoneal fluid Clinically important abnormalities in baseline hematologic, renal or hepatic laboratory values Renal failure Immunodeficiency Active pulmonary disease Peptic ulcer disease Hypersensitivity to MTX Coexistent viable intrauterine pregnancy Breastfeeding Unable to be monitored for resolution Do not have timely access to a medical institution |
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List relative contraindications or predictors of methotrexate failure
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bhCG <5000 mU/ml - 92% success rate
fetal cardiac activity ectopic size >=3-4cm |
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a) What is the mechanism of action of methotrexate?
b) How is methotrexate cleared from the body? |
a) Dihydrofolate reductase inhibitor
b) Renally |
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Prior to using methotrexate to treat ectopic pregnancy, what lab tests should be done?
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serum bhCG
CBC T&S (Rh status) LFT/LEs Creatinine |
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Describe the protocol for single-dose methotrexate treatment of ectopic pregnancy.
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Lab tests
TV-US WinRho (if Rh-) 50mg/m2 BSA IM MTX x 1 Monitor serum bhCG until zero Contraception ~6 months |
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Describe how bhCG should be followed post-MTX treatment for ectopic pregnancy.
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bhCG on day 4 and day 7 post-treatment
if > 15% drop, monitor bhCG weekly until zero if < 15% drop b/w day 4 & 7, give 2nd dose and reset protocol |
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What precautions should be taken when giving a women methotrexate for ectopic pregnancy?
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- Avoid vaginal intercourse and new conception until hCG is undetectable
- Avoid pelvic exams during surveillance of MTX therapy due to theoretical risk of tubal rupture - Avoid sun exposure to limit risk of MTX dermatitis - Avoid foods and vitamins containing folic acid - Avoid NSAIDs |
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Why is single-dose rather than multi-dose methotrexate for ectopic pregnancy used?
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Equivalent treatment efficacy
Less side effects |
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a) How long should women wait after receiving methotrexate for ectopic pregnancy before attempting to conceive again?
b) Why? |
a) At least 6 months
b) MTX can remain in the body for that long. |
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Is there good evidence that reproductive outcomes following salpingostomy versus salpingectomy for ectopic pregnancy are superior?
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No
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What is the rate of persistent ectopic (elevated bhCG) following salpingostomy?
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~10%
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