Ectopic Pregnancy- Dr.Neha

Ectopic pregnancy is described the condition of a fertilized ovum implanted outside the uterine cavity. Ectopic pregnancy was first recognized in 1693 by Busiere when he was examining the body of a prisoner executed in Paris. Gifford of England made a more complete report in 1731. Ectopic pregnancy has since become recognized as one of the more serious complications of pregnancy.

One of the leading causes of maternal morbidity and mortality around the globe. Today, early diagnosis of ectopic pregnancy is possible with highly sensitive and rapid β-human chorionic gonadotropin (β-hCG) assays and the aid of advanced vaginal ultrasonographicequipment. The benefit of early diagnosis is that expectant

medical therapy or conservative surgery becomes possible. Conservative management in the case of a small ectopic pregnancy that is present without rupture is usually successful when preservation of the oviduct to maintain or enhance fertility is important.

 

 Medical Treatment

 

The drug most frequently used for medical management of ectopic pregnancy

i s methotrexate, including potassium chloride (KCl), hyperosmolar glucose, prostaglandins, and RU-486. These agents may be givensystemically (intravenously, intramuscularly, or orally) or locally (laparoscopic directinjection, transvaginal ultrasonographically directed injection, or retrogradesalpingography). Other agents besides methotrexate are not recommended for the treatment of ectopic pregnancy because their safety and efficacy are not well documented.

 

 

Candidates for Methotrexate

According to AmericanCollege of Obstetricians and Gynecologists (ACOG) guidelines

 

Methotrexate therapy can be considered for those patients with confirmed, or high suspicion for, ectopic pregnancy who are hemodynamically stable with no evidence of rupture documents the

absolute contraindications to methotrexate therapy including breastfeeding, hepatic,renal, or hematologic disorders and known sensitivity to methotrexate.

 

A patient who is unable to comply with the follow-up protocol should not be offered medical management.

 

Contraindications to Medical Therapy

Absolute Contraindications

Hemodynamically unstable

Ruptured ectopic pregnancy

Unable to comply with medical management follow-up

Breastfeeding

Immunodeficiency

Alcoholism, alcoholic liver disease or chronic liver disease

Preexisting blood dyscrasias

Known sensitivity to methotrexate

Active pulmonary disease

Peptic ulcer disease

Hepatic, renal, or hematologic disorder

 

Relative Contraindications

Gestational sac larger than 3.5 cm

Embryonic cardiac motion

 

 

Methotrexate Dosing Regimens

 

Methotrexate is usually given via intramuscular injection but can be administered orally or by intravenous infusion.

 

Multidose Regimen

Administer MTX 1 mg/kg IM days 1, 3, 5, 7

Administer leucovorin 0.1 mg/kg days 2, 4, 6, 8

Measure β-hCG levels on days 1, 3, 5, 7 until 15% decrease between two measurements.Once β-hCG levels drop 15%, stop MTX and monitor β-hCG weekly untilnonpregnant level

 

Single-Dose Regimen:

Administer MTX 50 mg/m2 on day 0

Measure β-hCG level on days 4 and 7

If levels drop by 15%, monitor β-hCG weekly until nonpregnant level

If levels do not drop by 15%, repeat dose of MTX and measure β-hCG on days 4 and 7

 

Two-Dose Regimen

Administer MTX 50 mg/m2 on days 0 and 4

Measure β-hCG level on days 4 and 7

 

If levels drop by 15%, monitor β-hCG weekly until nonpregnant level

If levels do not drop by 15%, repeat dose of MTX on days 7 and 11 and measure β-hCG on days 7 and 11. If levels drop 15%, monitor β-hCG weekly until nonpregnant level MTX, methotrexate; IM, intramuscular; β-hCG, β-human chorionic gonadotropin.

 

Methotrexate Single-Dose Regimens

Single-dose regimens were designed to increase patient compliance and simplify the administration of methotrexate. This regimen is well studied and safe and effective in the treatment of ectopic pregnancies. Approximately 15% to 20% of patients in the single-dose regimen will require a second dose of methotrexate due to persistent β-hCG levels. The β-hCG level at the time of treatment appears to predict the subsequent success rate of single-dose therapy.

Patients with β-hCG levels greater than 5,000 mIU/mL have a 14.3% chance of treatment failure compared to only 3.7% for women with levels less than 5,000 mIU/mL.Compared with the multidose protocol, single-dose methotrexate is less expensive, patient acceptance is greater because less monitoring is required during treatment, and the treatment results and prospects for future fertility are comparable.

 

Patient Instructions

Refrain from alcohol use, multivitamins containing folic acid, NSAID use, and sexual intercourse until hCG level is negative.

Call your physician if: You experience prolonged or heavy vaginal bleeding.

The pain is prolonged or severe (lower abdomen and pelvic pain is normal during the first 10–14 days of treatment).

You use oral contraception or barrier contraceptive methods.

About 4%–5% of women experience unsuccessful methotrexate treatment and require surgery.

 

 

Patient Follow-Up

 

After intramuscular administration of methotrexate, regardless of the dose regimen used, patients are monitored on an outpatient basis with weekly β-hCG levels. These levels need to be monitored until the β-hCG reaches

nonpregnant levels. It is possible that tubal rupture may occur even if β-hCG levels are falling. Signs of a tubal rupture include severe pain, hemodynamic instability, and a drop in hematocrit.

 

 

Side Effects

 

Side effects of methotrexate therapy are dose and frequency dependent. The most commonly reported side effects are the gastrointestinal symptoms of nausea, vomiting, stomatitis, and abdominal pain.

Salpingocentesis is a technique in which agents such as KCl, methotrexate, prostaglandins, and hyperosmolar glucose are injected into the ectopic pregnancy transvaginally using ultrasonographic guidance, transcervical tubal cannulization, or laparoscopy. Agents injected under ultrasonographic guidance included methotrexate,KCl, combined methotrexate and KCl, and prostaglandin E2. The potential advantages of salpingocentesis include a one-time injection with the potential avoidance of systemic side effects. Reproductive function after this form of treatment was not reported. Because of the limited experience, this treatment cannot be recommended untilthere is further study. Agents injected into the amniotic sac at laparoscopy included prostaglandin F2a, hyperosmolar glucose, and methotrexate. This method has the obvious disadvantage of requiring laparoscopy, but it can be used if laparoscopy is performed fordiagnosis. Other agents reported for the treatment of ectopic pregnancy include RU-486 and anti-hCG antibody.

 

Surgical Management:

 

Conservative management of an unruptured ectopic pregnancy

usually consists of one of two possible procedures: linear salpingotomy

or segmental resection. A conservative surgical approach is possible when the diagnosis of ectopic pregnancy ismade sufficiently early so that rupture of the oviduct has not yet occurred.

 

Linear Salpingotomy. In women who wish to preserve their fertility, conservative surgery by linear salpingotomy is considered the gold standard for the management of a distal tubal pregnancy.

 

Laparoscopic Conservative Procedure. Currently, most ectopic pregnancies are treated by laparoscopic surgery. In fact, most studies have suggested that laparoscopic surgery is superior to laparotomy in hemodynamically stable patients. Advantagesof laparoscopy include lower cost, shorter hospital stay, less surgical blood loss, less analgesia requirement, and a shorter postoperative convalescence. Not all patients, however, may be suitable for laparoscopic treatment. These include patients with an unstable hemodynamic status, those with severe pelvic adhesions, and those with a specific contraindication to laparoscopy.

 

Segmental Resection. The optimal surgical approach to the

isthmic ectopic pregnancy remains controversial. Three conservative

operations have been described: segmental resection of the involved portion of oviduct with primary microsurgicalanastomosis, segmental resection with reanastomosis at a later operation, and linear salpingotomy.

 

Radical Surgical Treatment

Total salpingectomy is required when a tubal pregnancy hasruptured and a substantial hemoperitoneum has occurred. Inthese cases, the intraabdominal hemorrhage must be quicklycontrolled, and a conservative operation should not be attempted.

 

Salpingectomy versus Salpingostomy

There is debate about which surgical procedure is best. Salpingo-oophorectomy was once considered appropriate because it was theorized that this technique would eliminate transperitoneal migration of the ovum or zygote, which was thought to predispose to recurrent ectopic pregnancy. Ovarian removal results in all ovulations occurring on the side with the remaining normal fallopian tube. Subsequent studies have notconfirmed that ipsilateral oophorectomy increases the likelihood of conceiving an intrauterine pregnancy; therefore, this practice is not recommended. Whether to treat the ectopic pregnancy with a salpingostomy or salpingectomy is strongly debated and multiple studies investigated this issue. If one surgical technique resulted in higher treatment efficacy, lower rates of recurrent ectopic pregnancies, and higher rates of future intrauterine pregnancies, the decision would be clear.

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