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Pregnancy of Unknown Location “PUL”

Pregnancy of Unknown Location “PUL”. Kathryn Calhoun, MD May 9, 2012. Case. 32 yo G2P1001 LMP 10 wks ago 8 wga New Ob visit scheduled for next week Spotting, BLQ pain Diagnosis?. Case. Diagnosis: PUL with bleeding Differential Intrauterine pregnancy

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Pregnancy of Unknown Location “PUL”

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  1. Pregnancy of Unknown Location “PUL” Kathryn Calhoun, MD May 9, 2012

  2. Case • 32 yo G2P1001 • LMP 10 wks ago • 8 wga • New Ob visit scheduled for next week • Spotting, BLQ pain • Diagnosis?

  3. Case • Diagnosis: PUL with bleeding • Differential • Intrauterine pregnancy • “threatened abortion”, SABs 60% conceptions • Consider torsion, hemorrhagic CL • Ectopic pregnancy (2% conceptions) • Heterotopic pregnancy (1/4000 non-ART)

  4. What do you want to do? • History • Physical • Labs • Ultrasound

  5. History • PMH/PSH/Ob/Gyn/Social • Bleeding history • Amount? Duration? Passage of tissue? • Pain history • Focus on risk factors for ectopic • Major • Minor

  6. Risk factors for ectopic Major Risk Factors: • Previous Ectopic • 10% if one, 25% if two • Abnormal tubes • PID, surgery

  7. Risk factors for ectopic Minor Risk Factors: • Smoking cigarettes • Age > 35 • # lifetime sexual partners • IUD in place • Infertility • IVF (heterotopic 1/4000  1/100) • 50% have no risk factors

  8. Case • PMH: hypothyroidism • PSH: FTC/S – FTP • Gyn: No STIs, no abnlPaps, 3 lifetime partners, currently monogamous with husband – using withdrawal method • SH: Married, RN – labor floor, no T/D, social EtOH

  9. What do you want to do? • History • Physical • Labs • Ultrasound

  10. Physical • VS • UPT • Abdomen • Pelvic • Evaluate for acute abd but do not rupture ectopic! • Cervix open? • Blood or tissue present? • Float tissue or send to pathology

  11. Case • VS: 97.9, 120/70, P 101, RR 18, 99% RA • 5’8” 140lb • UPT: positive • Abd: soft, NT • Pelvic: NEFG, brown mucus, cervix closed • Assessment? • No acute abdomen • Does not need STAT OR

  12. What do you want to do? • History • Physical • Labs • Ultrasound

  13. Labs • Blood type • CBC • Quantitative HCG

  14. Case • O neg • Hgb 12 • HCG 4500

  15. What do you want to do? • History • Physical • Labs • Ultrasound

  16. Ultrasound • When is this helpful? • What should we see? • Quant 4500 • TV or Abdominal?

  17. Ultrasound expectations • By gestational age • 4-5 wga: GS, DD sign - 5.5: YS • 6 wga: FP - 6.2-6.5: +FHTs • By quantitative HCG level • 1500-3000: evidence of IUP (unless twins!) • By size of US structures • GS 8mm (TV) or 20mm (TA): should see YS • GS 16mm (TV) or 25mm (TA): should see FP • FP 5mm: should see FHTs

  18. Double Decidual Sign 2 layers of echogenicdecidua separated by a thin echolucent line. Not present at the site of placental development.

  19. A sac in the uterus Developing GS Endometrial cyst in basalis

  20. Measuring the GS: Mean Sac Diameter 3 dimensions: Length, Height, Width Measure from fluid/tissue interface to fluid/tissue interface

  21. Developing yolk sac When MSD 8mm (TV) or 20mm (TA) If no YS, then “empty sac”

  22. Fetal pole/embryo appears MSD 16mm (TV) or 25mm (TA) If not, “anembryonic gestation” or “blighted ovum” Measure fetal pole in Crown-Rump length (CRL) Needs FHT by CRL 5mm or “failed IUP”

  23. How do you manage a failed IUP?

  24. How do you manage a failed IUP? • Expectant • Medical (See Miso handout) • Cytotec 800mcg PV • Repeat 48hrs if no result • Surgical • Curettage in office or OR • Advantages: usually definitive • Disadvantages: Instrumentation, anesthesia

  25. Case: TV Ultrasound Thickened hyperechoic lining No sign of IUP

  26. So … now what?? • PUL, bleeding, BLQ pain • Quant 4500 • Thickened ES but no clear IUP

  27. Let’s look at the Adnexae!

  28. Adnexae Right Ovary Left Ovary

  29. Diagnosis?

  30. So … now what?? • DDX: • Hemorrhagic right CL with failing IUP • Right ovarian ectopic • Heterotopic • Plan: • Admit and observe? • OR?

  31. The CL can deceive … Hemorrhagic

  32. A recent non-topic at UNC ADJACENT MASS OVARY • 37 yo G3P2002 with cramping, VB • CBC WNL • HCG 9499 • ES 23mm

  33. Upon Laparoscopic Entry

  34. Laparoscopic Images Right ovary with CLC Normal right tube and mesosalpinx

  35. If you go to the OR … • You may be obligated to go to OR in patient with PUL, pain and adnexal mass • Surgical plan? • Outright LSC • D+C with frozen for POC • If negative, proceed with diagnostic LSC • If positive, check quant 24 hrs • Should fall 15-20%+ • What if it doesn’t fall? • Repeat imaging • Medical vs Surgical vs Expectant mgt as appropriate

  36. What if her imaging had looked like this?

  37. Diagnosis?

  38. Management of Ectopic Pregnancy • Surgical • Medical • Expectant • If HCG < 200 and declining

  39. Surgical Management of Ectopic • Only option if patient HD unstable • Stable patient • LSC with salpingostomy • Requires post-op quants +/- MTX • LSC salpingectomy

  40. What to do with the tubes?

  41. Medical Management of Ectopic • Methotrexate (MTX) • 1980s • Folic acid antagonist (chemotherapeutic) • Attacks actively proliferating cells • Rapidly cleared by kidneys • ~ 90% success rates in properly-selected patients

  42. Who can get MTX?

  43. MTX Contraindications ABSOLUTE RELATIVE Pain Ectopic > 3cm Ectopic with FHTs Blood in pelvis Location? HCG > 5000 May just decrease efficacy or increase chance of multi-dose • Unstable/rupturing • Non-compliant/No access • Coexistent IUP • Allergic to MTX • Renal, hepatic, pulmonary, hematologic or peptic ulcer disease • Immunodeficiency • Alcoholism • Breast-feeding

  44. MTX side effects • Pain • Bleeding • Stomatitis • GI upset • NSAIDs can exacerbate • Rarely renal/hepatic issues in women with normal baseline labs More frequent in successful treatments

  45. MTX: How do you give it? • If truly still a PUL, would consider evacuating uterus to prove ectopic before labeling patient and giving MTX

  46. MTX: How do you give it? • Verify normal baseline safety labs • CBC, Creatinine, LFTs • Dose: 50 mg/m2 (calculate BSA), IM shot • Stop PNV/folate, avoid sun exposure, avoid NSAIDs, pelvic rest until HCG <5 • Single dose vs. Two-dose vs. Multi-dose • Named for the intended # of doses

  47. Single dose MTX • Day 1: HCG, safety labs, MTX#1 • Day 4: HCG • Day 7: HCG, safety labs • Needs to drop by 15% from Day 4 or re-dose and recheck for 15% drop on Day 11 (2 Dose Protocol) • If it drops ≥ 15%, follow HCG Q week to <5

  48. Multi dose protocol • Add leucovorin 0.1mg/kg (LCV, folinic acid) to rescue normal cells • Day 1: HCG, safety labs, MTX#1 • Day 2: HCG, LCV #1 • Day 3: MTX #2 • Day 4: HCG, LCV #2 • Repeat sequence for up to 4 doses • When HCG drops by 15%, check weekly

  49. What if medical management fails? • Re-image • If imaging negative, evacuate uterus if not already done • Consider diagnostic LSC

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