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Ectopic Pregnancy

Ectopic Pregnancy. Incidence. 2% of all pregnancies 6% of maternal mortality 6 fold increase in ectopic 1970 to 1992 19.7 ectopics per 1000 pregancies , stable since 1992. Risk Factors. Prior PID especially chlamydia Prior ectopic pregnancy Prior tubal surgery History of infertility

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Ectopic Pregnancy

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  1. Ectopic Pregnancy

  2. Incidence • 2% of all pregnancies • 6% of maternal mortality • 6 fold increase in ectopic 1970 to 1992 • 19.7 ectopics per 1000 pregancies, stable since 1992

  3. Risk Factors • Prior PID especially chlamydia • Prior ectopic pregnancy • Prior tubal surgery • History of infertility • History of IUD usage • In vitro fertilization

  4. Diagnostic Tools • Clinical triad of delayed menes, pain, and abnormal bleeding • Ultrasound • Beta HCG • Progesterone

  5. Surgery • Laparotomy verses Laparoscopy • Conservative verses radical surgery

  6. Methotrexate • Single dose • 50 mg/sq meter IM • Multiple dose • MTX 1 mg/kg on d 0,2,4,6 • Leucovorin 0.1 mg/kg d 1,3,5,7

  7. Side Effects Associated with Methotrexate Treatment NauseaVomitingStomatitisDiarrheaGastric distressDizzinessSevere neutropenia (rare)Reversible alopecia (rare)Pneumonitis

  8. Treatment effects Increase in abdominal pain (occurs in up to two thirds of patients) Increase in Beta HCG levels during first 1-3 days of treatment Vaginal bleeding or spotting

  9. Signs of treatment failure and tubal rupture • Significantly worsening abdominal pain, regardless of change in hCG levels • Hemodynamic instability • Levels of hCG that do not decline by at least 15% between day 4 and day 7 post injection • Increasing or plateauing hCG levels after the first week of treatment

  10. 3/2 NJ is a 29 y/o GoPo complaining of no period PI: one month of intermittant low abd cramps Spotting on and off Gyn Hx: sexually active no birth control PE: Abdomen soft nontender Pelvic exam: no vaginal bleeding, Cx if closed, uterus is nontender, no adnexal mass or tenderness

  11. Quant Beta HCG = 3633 Ultrasound: 1 cm gestational sac in Left Adenexa

  12. 3/3 Methotrexate 50 mg/sq m IM 3/6 (day 4) Quant = 6019 3/9 (day 7) Quant = 5817 (3.3% decrease)

  13. 3/10 Methotrexate 50 mg/ sq m IM 3/13 (day 4) Quant = 4100 3/16 (day 7) Quant = 2609 (54% decrease)

  14. 3/2 NJ is a 29 y/o GoPo complaining of no period PI: one month of intermittant low abd cramps Spotting on and off Gyn Hx: sexually active no birth control PE: Abdomen soft nontender Pelvic exam: no vaginal bleeding, Cx if closed, uterus is nontender, no adnexal mass or tenderness

  15. Quant = 1500 Ultrasound show gestational sac in the uterus

  16. 3/16 CC: cramping continues on and off but the bleed is more like a menstral period Pelvic exam shows menstral blood in the vagina but the cervix is slightly dilated, uterus and adenexa are tender but no masses felt Ultrasound shows thickened endometrium with no gestational sac as seen 2 weeks ago

  17. Quant = 4500

  18. Path report shows chorionic villi

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