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MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY

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MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY Cary L. Clarke, MD Definition Pregnancy located outside the uterus Most common site is in the fallopian tube Tubal pregnancy ... – PowerPoint PPT presentation

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Title: MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY


1
MEDICAL MANAGEMENT OF ECTOPIC PREGNANCY
  • Cary L. Clarke, MD

2
Definition
  • Pregnancy located outside the uterus
  • Most common site is in the fallopian tube
  • Tubal pregnancy may be the most dangerous
  • Abdominal pregnancy may be carried to term in
    some patients

3
Incidence and Impact
  • Occurs in 1 in 50 pregnancies
  • Is becoming increasingly more common
  • Is the second leading cause of maternal mortality
    overall, and primary mortality factor in first
    trimester pregnancies
  • May lead to impairment or loss of fertility

4
Risk Factors
  • Previous ectopic pregnancy
  • Tubal damage from infection or surgery
  • Increased age (more common after 35)
  • Smoking (?)
  • Use of an Intrauterine Device

5
  • Assisted reproduction (GIFT, IVF, ovulation
    induction)
  • Tubal ligation
  • History of infertility (implying underlying
    damage)
  • History of PID (C.Trachomatis especially) is a
    predictor of ectopic pregnancy risk

6
Symptoms (early)
  • Amenorrhea for an average of 7 weeks
  • Abdominal pain (usually lateral)
  • Caveat some women have no pain, and about
    one-third of women will not have adnexal
    tenderness.
  • Vaginal bleeding after an interval of amenorrhea
  • may include uterine cast, the pregnancy
    endometrium which is sloughed with loss of
    progesterone from corpus luteum failure

7
Symptoms (later)
  • Hemodynamic instability
  • Peritoneal signs/acute abdomen
  • Distended, silent, doughy abdomen
  • Shoulder pain

8
Pathophysiology
  • Conceptus lodges and implants in tube
  • Positive beta-HCG and symptoms of pregnancy
  • Overdistension of the tube eroding the blood
    vessels supplying the corpus luteum
  • Failure of the pregnancy
  • Bleeding into the abdominal cavity

9
Natural history
  • May regress spontaneously
  • Abortion out the end of the tube
  • Chronic hematoma formation
  • Reimplantation elsewhere (abdominal pregnancy)

10
Diagnosis
  • History and physical
  • any woman presenting with pain and vaginal
    bleeding should be considered to have an ectopic
    pregnancy until otherwise ruled out

11
  • Laboratory markers
  • Beta-HCG(measured in mIU/mL) --lack of doubling
    signals only impending failure, not indicative of
    locationabsolute value only helpful in
    correlation with ultrasound
  • Progesterone--also only indicates impending loss,
    not location

12
  • Ultrasound--transvaginal is most sensitive at
    this stage of pregnancy.
  • Correlation with the quantitative serum hormone
    levels is suggested to increase your sensitivity
  • if intrauterine gestational sac is seen and b-HCG
    is 1,000-2,000, normal pregnancy is virtually
    certain.
  • If b-HCG is lt1,000 and there is an empty uterus,
    ectopic pregnancy is very likely

13
  • if b-HCG is is less than 1,000 and definite
    intrauterine ring of pregnancy is seen, SAB is
    imminent. Serum progesterone may be helpful (if
    less than 5ng/mL, pregnancy is nonviable).

14
Finding Ectopic risk
  • No mass or free fluid
  • Any free fluid
  • Echogenic mass
  • Moderate to large amount fluid
  • Echogenic mass and fluid
  • 20
  • 71
  • 85
  • 95
  • 100

15
Treatment Options
  • Surgery
  • Tube sparing salpingotomy--used when gestational
    sac is lt2cm and in distal tube lateral incision
    made and gestational sac removed
  • Tube sacrificing salpingectomy
  • Expectant mangagment
  • b-HCG is lt1000 and falling, there is minimal pain
    and bleeding, and patient is reliable for
    follow-up

16
  • Methotrexate
  • Requires proper patient selection
  • Spares patient from surgery and its risks
  • Does not require hospitalization
  • May help preserve future fertility

17
Patient Selection
  • Hemodynamically stable
  • No medical contraindications (normal LFTs, renal
    function, CBC and Plt)
  • Unruptured ectopic pregnancy
  • Absence of embryonic cardiac activity
  • Ectopic mass 4cm or less
  • Starting b-HCG lt5,000mIU/mL
  • Reliable for follow up

18
Mechanism of Action
  • Methotrexate is an antimetabolite which inhibits
    the reduction of folic acid to tetrahydrofolate.
    This interferes with DNA synthesis and cell
    multiplication. Ideal for disrupting
    trophoblastic tissue proliferation.

19
Success Rate
  • Defined as resolution of pregnancy without
    surgery
  • Systemic administration carries a rate between
    85 and 95, with preservation of fertility
  • Single dose regimens are essentially as
    effective, with fewer side effects
  • If a second dose is required, success rate is
    around 98

20
Method of administration
  • May inject into the gestational sac under
    ultrasound guidance
  • Single dose systemic treatment
  • Methotrexate 50mg/M2 body surface area
  • Usual dose range is 50-120 mg, average dose is
    80-90mg
  • Injected IM

21
Follow up
  • b-HCG is measured on days 1,4 and 7
  • If hormone levels fail to decline at least 15
    between days 4 and 7, or at least 15 each week
    thereafter, repeat methotrexate dosing.
  • Average time to resolution
  • for single administration, 26days
  • two dose patients, 48 days

22
  • Failure to resolve
  • if the serial quantitative analysis fails to
    reach near zero levels, patient needs further
    ultrasonographic evaluation and possible
    exploratory surgery.

23
Surgical Consultation
  • Cervical pregnancy
  • Tubal rupture
  • Broad ligament pregnancy
  • Interstitial/Cornuate pregnancy (implantation at
    the segment of tube penetrating uterine wall)
  • Heterotypic ectopic (concurrent ectopic and
    intrauterine pregnancies)
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