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Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
Management of tubal ectopic pregnancy
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Management of tubal ectopic pregnancy

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  • 1. Management of ectopic pregnancy
    Dr.V.Ravimohan
  • 2. Incidence 11.1/1000 pregnancies
    Treatment options
    1.Expectant
    2.Medical
    3.Surgical
  • 3. Ruptured ectopic with collapse
    Get help- call senior SPR/Consultant on call and anaesthetist
    ABC of resuscitation
    give facial oxygen
    Site two IV lines (at least 16g), commence IV fluids (crystalloid)
    Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.
    insert indwelling catheter
    arrange theatre for laparotomy
    whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state
    do not wait for BP and pulse to normalise prior to transfer-resuscitation and surgery need to go hand in hand.
    Pfannensteil incision, locate tube directly and clamp
    salpingectomy and wash out of abdomen
    assess bloods consider CVP / HDU discuss with anaesthetist
    record operative findings including the state of the remaining tube/pelvis
    Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women
  • 4. Surgical Management
  • 5. Salpingectomy Vs Salpingotomy
    No randomised controlled studies available
    Evidence from observational studies
    Case series
    Cohort
    Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contra lateral tubal disease and the desire for future fertility.
  • 6.
  • 7. Persistent trophoblast
    When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast.
    Monitoring serum HCG levels would help to identify the pesistenttrophoblast.
  • 8. Criteria for medical therapy
    Selection criteria
    Minimal symptoms
    HCG <3,000
    Absence of fetal heart beat
    Normal FBC,U&E(urea & electrolytes),LFT(liver function tests)
    Exclusion creiteria
    Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood dyscrasia(WCC <2000 cells cm3).
    Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35days).
    Ectopic mass >3.5mm
    The presence of cardiac activity in an ectopic pregnancy
    Women on concurrent corticosteroid therapy
  • 9. Medical management
    Treatment
    Methotrexate-Intramuscular(buttock or lateral thigh)
    Dose calculated from body surface area
    Usual dose ranges between 75-95 mg
    HCG checked on day 4 & day 7
    If fall is less than 15 % consider second dose of methotrexate
    • The empty syringe or needle should be placed in a separate Sharp Safe, labelled “Cytotoxic waste forspecial incineration”
    • 10. Anti-D should also be given if required
    • 11. Rest up to one hour after the injection.
    • 12. Check for any local reaction.
    • 13. If local reaction noted consider anti-histamine or steroid cream (very rare).
  • Patient undergoing medical management
    14 % of medical management second dose of methotrexate
    75% would experince abdominal pain-separation pain.This usually occurs between day 3-7
    10% would finally require surgical management
  • 14. Medical management....
    Patient should be given information on(preferably written)
    Need for further treatment
    Adverse effects
    Women should be able to return easily for assessment at any time during follow-up
    Advice
    avoid sexual intercourse during treatment
    to maintain ample fluid intake
    use reliable contraception for three months after methotrexate has been given, because of a possible teratogenic risk.(barrier or hormonal)
    side effects of the drug are minimal but may include nausea, vomiting and stomatitis.
    avoid alcohol or folic acid containing vitamins during treatment.
    Avoid exposure to sunlight.
    Outcome
    90% successful treatment with single dose regime.
    Recurrent ectopic pregnancy rate 10 – 20%.
    Tubal patency approximately 80%.
  • 15. Medical management....
    Day 1- Do FBC, LFTs, U &Es, serum hCG and give Methotrexate
    Day 4 – Do serum hCG
    Day 7 – Do serum hCG, FBC, LFTs and U&Es
    On day 4 and day 7 blood results should be reviewed by the doctor with regard to resolution, need for a second dose or surgical treatment.
    Then blood tests should be repeated once or twice weekly until levels of hCG drop below 20 IU/L.
  • 16. Cost benefit
    Medical management is cheap in the initial period
    but considering the cost of follow up & the loss of work time for patient & carers
    no cost saving was seen at serum hCG levels above 1500 iu/l due to the increased need for further treatment and prolonged follow-up.
  • 17. Expectant management of pregnancy of ectopic pregnancy
    Criteria for selection
    asymptomatic women with an ultrasound diagnosis of ectopic pregnancy.
    less than 100 ml fluid in the pouch of Douglas
    decreasing hCG levels that are less than hCG 1000 iu/l at initial presentation
    Adnexal mass less than 4 or 5 cm was the cut off for the studies assessing expectant management.
  • 18. Monitoring
    Initial follow up
    twice weekly with serial hCGmeasurements
    weekly by transvaginal examinations
    By the first week
    drop in HCG level more than 50%
    Adnexal mass size more than 50%
    Otherwise reassess the options (Medical/Surgical)
    If the fall of HCG & reduction in size of adnexal mass satisfatory
    weekly hCG and transvaginal ultrasound examinations
    Till the HCG falls less than <20 IU
  • 19. Expectant management of pregnancy of unknown location
    Selection criteria
    Clinically stable patient with minimal symptoms
    initial upper level of serum hCG of 1000–1500 iu/l
    Explain the possibility ectopic pregnancy to the patient.
    44–69% of pregnancies of unknown location resolve spontaneously with expectant management
    Ectopic pregnancy was subsequently diagnosed in 14–28% of cases of pregnancy of unknown location
    Intervention has been shown to be required in 23–29% of cases.
  • 20. Anti-D immunoglobulin
    Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.
    Dose 250 IU
  • 21. Follow up
    Women must be made aware of the risk of a further ectopic pregnancy
    My Web site www.mrcogexam.net
    Twitter: www.twitter.com/ravimohanv
    http://about.me/Ravimohan2
    Source: Royal college of Obstetericians & Gynaecologists Guideline

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