This document discusses various topics related to ectopic pregnancy including causes, diagnosis, and treatment options. It provides details on:
1. Causes of bleeding in early pregnancy such as implantation bleeding and ectopic pregnancy. Ectopic pregnancy remains a significant cause of pregnancy related deaths.
2. Diagnosis of ectopic pregnancy including using beta-hCG levels and transvaginal ultrasound to visualize the pregnancy location. Ectopic pregnancies are most commonly located in the fallopian tubes.
3. Treatment options for tubal ectopic pregnancies including expectant management, pharmacological management using methotrexate, and surgical management. It provides protocols for single dose, two dose, and multiple dose methot
Ectopic pregnancy medical management wanjala 2012Lagendary_MD
This document discusses the medical management of ectopic pregnancies. It outlines predictors of success with methotrexate treatment, including initial beta-hCG levels and ectopic mass size. The available options for medical management - single dose methotrexate, multi-dose methotrexate, methotrexate with mifepristone, and hyperosmolar glucose injection - are described and compared. Expectant management is an option for select asymptomatic patients. The document also reviews monitoring, contraindications, complications, costs and challenges to medical management of ectopic pregnancies.
This study compared the efficacy of double-dose and single-dose methotrexate protocols for treating ectopic pregnancies. It found:
1. The overall success rate was higher but not significantly different for the double-dose protocol (88%) compared to the single-dose protocol (82%).
2. The double-dose protocol had significantly higher success rates than the single-dose protocol for patients with initial β-hCG levels between 3600-5500 mIU/ml and ectopic mass diameters between 2.7-3.5 cm.
3. The double-dose protocol may be more effective for patients with higher β-hCG levels and larger ectopic mass sizes because the closer proximity
Madical treatment of ectopic pregnancy .Prof. Salah RoshdySalah Roshdy AHMED
This document discusses the medical management of ectopic pregnancy. It provides a brief history, epidemiology, risk factors, types of ectopic pregnancies. It discusses the lines of management including medical and surgical options. It examines methotrexate regimens used for medical management, comparing effectiveness and adverse effects. It also compares medical and surgical management outcomes and complications. Guidelines for treatment are provided based on the level of evidence.
Medical management of ectopic pregnancydr_sarkar54
This document outlines the medical management of ectopic pregnancies. It describes the criteria for using medical management, including gestational sac size and beta HCG levels. The main drug used is methotrexate, which works by depleting folate cofactors and inhibiting trophoblast growth. Methotrexate can be given as a single intramuscular dose or multiple doses over days, monitoring beta HCG levels. Other drugs like potassium chloride, prostaglandins, and hyperosmolar glucose can also be locally injected under ultrasound guidance to terminate the ectopic pregnancy. Contraindications for methotrexate are also listed.
Ovarian Stimulation in IUI- Overview. Dr. jyoti Bhaskar, Dr. Sharda Jain, Dr....Lifecare Centre
The document discusses ovarian stimulation protocols for IUI. It describes the rationale for controlled ovarian hyperstimulation in IUI as increasing the number of eggs available for fertilization and overcoming subtle defects in ovulation. The optimal stimulation is described as achieving 2-3 follicles 18-20mm in size with a thick trilaminar endometrium. Clomiphene citrate, tamoxifen, and various gonadotropins are discussed as drugs used for ovarian stimulation for IUI. Low dose gonadotropin protocols are recommended to increase success rates while minimizing risks of multiples and OHSS.
Ovulation induction protocols in ivf cycles. wardaOsama Warda
This document outlines ovarian stimulation protocols for fertility treatments. It discusses using clomiphene citrate or gonadotropins like hMG or FSH with timed intercourse or IUI initially. For more advanced treatments, it describes using birth control pills followed by gonadotropins and a HCG trigger before retrieving eggs through retrieval. It also notes drawbacks of the short stimulation protocol and compares the composition and activity of different gonadotropin medications.
Cracking the contraceptive myths barrierschaimingcheng
The document discusses common myths and facts regarding various contraceptive methods. It begins by addressing myths around natural family planning methods like coitus interruptus and fixed fertility periods, then discusses myths around perineal washing and breastfeeding preventing pregnancy. It also addresses myths around potential side effects of contraceptive pills like weight gain, reduced sexual drive, infertility, and malignancy. The document provides facts from studies to dispel each myth.
This document discusses ovulation induction using gonadotropin preparations. It outlines the different types of gonadotropins including human menopausal gonadotropins (hMG), urofollitropin, highly purified FSH, and recombinant gonadotropins. The main indications for gonadotropin use are hypogonadotropic hypogonadism, clomiphene-resistant anovulation, unexplained infertility, and elderly patients. Various protocols are described such as step-up, step-down, chronic low-dose, and fixed dose regimens. Complications include ovarian hyperstimulation syndrome. The document recommends that gonadotropins only be used by
Ectopic pregnancy medical management wanjala 2012Lagendary_MD
This document discusses the medical management of ectopic pregnancies. It outlines predictors of success with methotrexate treatment, including initial beta-hCG levels and ectopic mass size. The available options for medical management - single dose methotrexate, multi-dose methotrexate, methotrexate with mifepristone, and hyperosmolar glucose injection - are described and compared. Expectant management is an option for select asymptomatic patients. The document also reviews monitoring, contraindications, complications, costs and challenges to medical management of ectopic pregnancies.
This study compared the efficacy of double-dose and single-dose methotrexate protocols for treating ectopic pregnancies. It found:
1. The overall success rate was higher but not significantly different for the double-dose protocol (88%) compared to the single-dose protocol (82%).
2. The double-dose protocol had significantly higher success rates than the single-dose protocol for patients with initial β-hCG levels between 3600-5500 mIU/ml and ectopic mass diameters between 2.7-3.5 cm.
3. The double-dose protocol may be more effective for patients with higher β-hCG levels and larger ectopic mass sizes because the closer proximity
Madical treatment of ectopic pregnancy .Prof. Salah RoshdySalah Roshdy AHMED
This document discusses the medical management of ectopic pregnancy. It provides a brief history, epidemiology, risk factors, types of ectopic pregnancies. It discusses the lines of management including medical and surgical options. It examines methotrexate regimens used for medical management, comparing effectiveness and adverse effects. It also compares medical and surgical management outcomes and complications. Guidelines for treatment are provided based on the level of evidence.
Medical management of ectopic pregnancydr_sarkar54
This document outlines the medical management of ectopic pregnancies. It describes the criteria for using medical management, including gestational sac size and beta HCG levels. The main drug used is methotrexate, which works by depleting folate cofactors and inhibiting trophoblast growth. Methotrexate can be given as a single intramuscular dose or multiple doses over days, monitoring beta HCG levels. Other drugs like potassium chloride, prostaglandins, and hyperosmolar glucose can also be locally injected under ultrasound guidance to terminate the ectopic pregnancy. Contraindications for methotrexate are also listed.
Ovarian Stimulation in IUI- Overview. Dr. jyoti Bhaskar, Dr. Sharda Jain, Dr....Lifecare Centre
The document discusses ovarian stimulation protocols for IUI. It describes the rationale for controlled ovarian hyperstimulation in IUI as increasing the number of eggs available for fertilization and overcoming subtle defects in ovulation. The optimal stimulation is described as achieving 2-3 follicles 18-20mm in size with a thick trilaminar endometrium. Clomiphene citrate, tamoxifen, and various gonadotropins are discussed as drugs used for ovarian stimulation for IUI. Low dose gonadotropin protocols are recommended to increase success rates while minimizing risks of multiples and OHSS.
Ovulation induction protocols in ivf cycles. wardaOsama Warda
This document outlines ovarian stimulation protocols for fertility treatments. It discusses using clomiphene citrate or gonadotropins like hMG or FSH with timed intercourse or IUI initially. For more advanced treatments, it describes using birth control pills followed by gonadotropins and a HCG trigger before retrieving eggs through retrieval. It also notes drawbacks of the short stimulation protocol and compares the composition and activity of different gonadotropin medications.
Cracking the contraceptive myths barrierschaimingcheng
The document discusses common myths and facts regarding various contraceptive methods. It begins by addressing myths around natural family planning methods like coitus interruptus and fixed fertility periods, then discusses myths around perineal washing and breastfeeding preventing pregnancy. It also addresses myths around potential side effects of contraceptive pills like weight gain, reduced sexual drive, infertility, and malignancy. The document provides facts from studies to dispel each myth.
This document discusses ovulation induction using gonadotropin preparations. It outlines the different types of gonadotropins including human menopausal gonadotropins (hMG), urofollitropin, highly purified FSH, and recombinant gonadotropins. The main indications for gonadotropin use are hypogonadotropic hypogonadism, clomiphene-resistant anovulation, unexplained infertility, and elderly patients. Various protocols are described such as step-up, step-down, chronic low-dose, and fixed dose regimens. Complications include ovarian hyperstimulation syndrome. The document recommends that gonadotropins only be used by
Evolution and current practices in emergency contraceptives BY DR ALKA MUKHER...alka mukherjee
This document provides information on emergency contraceptives, including their evolution and current practices. It discusses various emergency contraceptive methods such as the Yuzpe regimen, levonorgestrel pills, mifepristone, copper IUDs, and the recently approved ulipristal acetate. It summarizes the mechanisms of action, effectiveness, appropriate timing, side effects, limitations and safety considerations of the different emergency contraceptive options. The document concludes that emergency contraception can effectively reduce unintended pregnancies and abortions if provided correctly and in a timely manner after unprotected intercourse.
This document discusses different methods for inducing ovulation, including clomiphene citrate, letrozole, and gonadotropins. Clomiphene citrate is often the first line treatment for anovulatory infertility and works by selectively blocking estrogen receptors in the hypothalamus. Letrozole is an aromatase inhibitor that prevents estrogen production and induces monofollicular development. Gonadotropins such as FSH can be used when other methods fail or for assisted reproduction procedures, but carry risks of ovarian hyperstimulation syndrome.
Parenteral hormonal injections can be used for various medical purposes such as birth control, weight loss, contraception, and treating cancers or hormonal imbalances. Common hormonal injections include Depo-Provera for contraception and testosterone-lowering injections for prostate cancer. Hormonal injections are administered via intramuscular, subcutaneous, or intravenous routes. Proper storage of hormonal injections is necessary to prevent microbial contamination.
The document summarizes the history and development of oral contraception. It discusses key figures like Ludwig Haberlandt, Russell Marker, Carl Djerassi, and Gregory Pincus who contributed to early research. It also describes the components of combination oral contraceptives including estrogens like ethinyl estradiol and progestins like norethindrone. The mechanisms of action and efficacy of combination oral contraceptives are explained.
This document discusses several types of gynecological cancers that commonly affect women, including cervical, uterine, and ovarian cancer. It provides information on risk factors, prevention methods like HPV vaccination and cancer screening, signs and symptoms, and treatment types. The three most common cancers are breast, colorectal, and cervical cancer. Cervical cancer can often be linked to HPV infection and lacks symptoms in early stages. Screening through Pap tests and HPV testing is effective for prevention and early detection.
This document discusses liver diseases and gastrointestinal issues that can occur during pregnancy. It provides information on:
1) Common gastrointestinal changes in pregnancy like heartburn, delayed gastric emptying, and constipation.
2) Liver function test changes that are normal during pregnancy.
3) Specific liver diseases related to pregnancy like hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, and HELLP syndrome.
4) Evaluation and management of nausea and vomiting during pregnancy as well as intrahepatic cholestasis of pregnancy.
1) Approximately 5% of women who give birth in England and Wales have either pre-existing diabetes or gestational diabetes. Proper management of diabetes during pregnancy is important for both maternal and fetal health.
2) Women with pre-existing diabetes have an increased risk of complications during pregnancy like hypoglycemia, infection, and deterioration of other conditions. Their babies also face higher risks of abnormalities, mortality, and other issues.
3) Close monitoring of blood glucose levels, medical nutrition therapy, insulin treatment when needed, and other care can help minimize risks during pregnancy for women with diabetes.
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses vasomotor symptoms (VMS) associated with menopause. It provides details on:
- VMS affect most menopausal women and include hot flashes and night sweats. Symptoms typically last 5-7 years.
- VMS are caused by estrogen withdrawal and a narrowing of the body's thermoregulatory zone. Small temperature changes can trigger sweating or shivering responses.
- Management options include lifestyle changes, non-hormonal therapies like SSRIs, and hormone replacement therapy (HRT). HRT using the lowest effective dose of estrogen is the most effective treatment for reducing VMS.
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
Gestational trophoblastic disease (GTD) is a group of pregnancy-related conditions that develop inside a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta. The placenta is the organ that develops during pregnancy to feed the fetus.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
Dr. Sharda Jain, Dr. Jyoti Agarwal, and Dr. Jyoti Bhaskar presented an interactive session on the medical management of dysfunctional uterine bleeding (DUB) in 2014. Ormeloxifene, a selective estrogen receptor modulator, was discussed as a non-steroidal treatment option for DUB that has shown efficacy in several pilot studies and randomized controlled trials. Ormeloxifene has advantages of a convenient dosing schedule and few side effects, and has been used to successfully treat over 700 patients with DUB. Feedback was encouraged from participants on experiences treating DUB.
This document discusses choices for childbirth and labor care. It recommends:
- Providing antenatal education on signs of labor and pain management options.
- Encouraging low-risk women to choose midwife-led care at home or a birth center for increased normal birth outcomes.
- Ensuring standardized high quality care across all birth settings, including access to midwives and pain relief options.
- Conducting early assessments of women in labor to provide support, information and determine if transfer is needed.
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANIDR SHASHWAT JANI
The document discusses several changes that have occurred in the field of obstetrics over recent decades. It notes that obstetrics has undergone significant development in properly understanding pregnancy and childbirth. However, this has led to higher expectations from all parties involved. It also discusses trends in rising maternal age, new medical disorders in pregnancy, increasing patient knowledge and demands, greater focus on preconception care, changes in antenatal care models and testing, rising rates of caesarean sections and complications like placenta accreta, and the growth of fields like fetal medicine. The practicing obstetrician must continue adapting to ongoing changes in the field.
Oral contraceptive pills (OCPs) contain synthetic hormones, usually a combination of estrogen and progestin, that prevent pregnancy through multiple mechanisms. They work by inhibiting ovulation, thickening cervical mucus, and thinning the uterine lining. Common estrogen and progestin components include ethinyl estradiol and levonorgestrel. OCPs are generally safe and effective when used correctly, with failure rates around 0.1% per year. They also provide non-contraceptive benefits like reducing menstrual cramps and risk of certain cancers. Doctors should screen for contraindications before prescribing OCPs.
This document discusses renal diseases in pregnancy. It begins by noting that urinary tract infections are common in pregnancy and can cause maternal and fetal complications. It then discusses how renal disease can be a risk factor for preeclampsia and fetal growth restriction. The document provides details on renal adaptation during pregnancy, management of urinary tract infections and pyelonephritis, renal stones, and the effects of pregnancy on pre-existing renal impairment. It emphasizes the importance of pre-pregnancy counseling and management for women with renal disease.
1) Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation therapy that can range from mild to severe or even life-threatening. It is characterized by ovarian enlargement and fluid shift into the body's tissues.
2) Risk factors for OHSS include high AMH levels, PCOS, previous OHSS, and high follicle counts and estrogen levels during treatment. Clinicians must monitor for OHSS and be prepared to manage it.
3) Management strategies aim to prevent OHSS through individualized protocols, or to treat symptoms by delaying hCG, using lower hCG doses, cryopreserving all embryos, or cancelling cycles if needed. Secondary prevention after trigger includes
This document discusses the many non-contraceptive benefits of combined oral contraceptives (COCP). It notes that 33% of adolescents using COCP do so for non-contraceptive reasons approved by research. COCP can effectively treat conditions like dysmenorrhea, dysmenorrhea, signs of androgenization, PMS, ovarian cysts, endometriosis, adenomyosis, myoma, and others. It discusses the mechanisms by which COCP provides these benefits and provides evidence from multiple studies. The document emphasizes that understanding these non-contraceptive benefits can enhance healthcare providers' care of patients.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It details the risk factors, symptoms, diagnostic process, and management options for ectopic pregnancies. Management may involve expectant monitoring, medical treatment with methotrexate, or surgical intervention depending on the individual case. Proper treatment is important to preserve future fertility and prevent life-threatening complications from tubal rupture.
This document discusses ectopic pregnancy, providing definitions and discussing incidence, etiology, clinical presentation, investigations, management of pregnancy of unknown location, and treatment approaches. Some key points:
- Ectopic pregnancies occur when implantation occurs outside the uterus, most commonly in the fallopian tubes. Risk factors include pelvic infections, previous ectopic pregnancies, and tubal damage.
- Patients often present with abdominal pain and vaginal bleeding. Diagnosis involves transvaginal ultrasound, serum hCG levels, and ruling out intrauterine pregnancy.
- Pregnancies of unknown location require serial hCG measurements and potentially endometrial biopsy to determine pregnancy location when ultrasound is inconclusive.
This document discusses early pregnancy bleeding and differentials, implantation in early pregnancy, ultrasound findings, miscarriage definitions and management options, ectopic pregnancy risk factors and treatments, and recurrent miscarriage evaluation. It defines miscarriage as loss of intrauterine pregnancy before 24 weeks and describes expectant, medical, and surgical management options. For ectopic pregnancies, it notes fallopian tubes as the most common site and lists risk factors. Treatment may involve methotrexate or laparoscopic salpingectomy.
Evolution and current practices in emergency contraceptives BY DR ALKA MUKHER...alka mukherjee
This document provides information on emergency contraceptives, including their evolution and current practices. It discusses various emergency contraceptive methods such as the Yuzpe regimen, levonorgestrel pills, mifepristone, copper IUDs, and the recently approved ulipristal acetate. It summarizes the mechanisms of action, effectiveness, appropriate timing, side effects, limitations and safety considerations of the different emergency contraceptive options. The document concludes that emergency contraception can effectively reduce unintended pregnancies and abortions if provided correctly and in a timely manner after unprotected intercourse.
This document discusses different methods for inducing ovulation, including clomiphene citrate, letrozole, and gonadotropins. Clomiphene citrate is often the first line treatment for anovulatory infertility and works by selectively blocking estrogen receptors in the hypothalamus. Letrozole is an aromatase inhibitor that prevents estrogen production and induces monofollicular development. Gonadotropins such as FSH can be used when other methods fail or for assisted reproduction procedures, but carry risks of ovarian hyperstimulation syndrome.
Parenteral hormonal injections can be used for various medical purposes such as birth control, weight loss, contraception, and treating cancers or hormonal imbalances. Common hormonal injections include Depo-Provera for contraception and testosterone-lowering injections for prostate cancer. Hormonal injections are administered via intramuscular, subcutaneous, or intravenous routes. Proper storage of hormonal injections is necessary to prevent microbial contamination.
The document summarizes the history and development of oral contraception. It discusses key figures like Ludwig Haberlandt, Russell Marker, Carl Djerassi, and Gregory Pincus who contributed to early research. It also describes the components of combination oral contraceptives including estrogens like ethinyl estradiol and progestins like norethindrone. The mechanisms of action and efficacy of combination oral contraceptives are explained.
This document discusses several types of gynecological cancers that commonly affect women, including cervical, uterine, and ovarian cancer. It provides information on risk factors, prevention methods like HPV vaccination and cancer screening, signs and symptoms, and treatment types. The three most common cancers are breast, colorectal, and cervical cancer. Cervical cancer can often be linked to HPV infection and lacks symptoms in early stages. Screening through Pap tests and HPV testing is effective for prevention and early detection.
This document discusses liver diseases and gastrointestinal issues that can occur during pregnancy. It provides information on:
1) Common gastrointestinal changes in pregnancy like heartburn, delayed gastric emptying, and constipation.
2) Liver function test changes that are normal during pregnancy.
3) Specific liver diseases related to pregnancy like hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, and HELLP syndrome.
4) Evaluation and management of nausea and vomiting during pregnancy as well as intrahepatic cholestasis of pregnancy.
1) Approximately 5% of women who give birth in England and Wales have either pre-existing diabetes or gestational diabetes. Proper management of diabetes during pregnancy is important for both maternal and fetal health.
2) Women with pre-existing diabetes have an increased risk of complications during pregnancy like hypoglycemia, infection, and deterioration of other conditions. Their babies also face higher risks of abnormalities, mortality, and other issues.
3) Close monitoring of blood glucose levels, medical nutrition therapy, insulin treatment when needed, and other care can help minimize risks during pregnancy for women with diabetes.
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses vasomotor symptoms (VMS) associated with menopause. It provides details on:
- VMS affect most menopausal women and include hot flashes and night sweats. Symptoms typically last 5-7 years.
- VMS are caused by estrogen withdrawal and a narrowing of the body's thermoregulatory zone. Small temperature changes can trigger sweating or shivering responses.
- Management options include lifestyle changes, non-hormonal therapies like SSRIs, and hormone replacement therapy (HRT). HRT using the lowest effective dose of estrogen is the most effective treatment for reducing VMS.
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
Gestational trophoblastic disease (GTD) is a group of pregnancy-related conditions that develop inside a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta. The placenta is the organ that develops during pregnancy to feed the fetus.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
Dr. Sharda Jain, Dr. Jyoti Agarwal, and Dr. Jyoti Bhaskar presented an interactive session on the medical management of dysfunctional uterine bleeding (DUB) in 2014. Ormeloxifene, a selective estrogen receptor modulator, was discussed as a non-steroidal treatment option for DUB that has shown efficacy in several pilot studies and randomized controlled trials. Ormeloxifene has advantages of a convenient dosing schedule and few side effects, and has been used to successfully treat over 700 patients with DUB. Feedback was encouraged from participants on experiences treating DUB.
This document discusses choices for childbirth and labor care. It recommends:
- Providing antenatal education on signs of labor and pain management options.
- Encouraging low-risk women to choose midwife-led care at home or a birth center for increased normal birth outcomes.
- Ensuring standardized high quality care across all birth settings, including access to midwives and pain relief options.
- Conducting early assessments of women in labor to provide support, information and determine if transfer is needed.
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANIDR SHASHWAT JANI
The document discusses several changes that have occurred in the field of obstetrics over recent decades. It notes that obstetrics has undergone significant development in properly understanding pregnancy and childbirth. However, this has led to higher expectations from all parties involved. It also discusses trends in rising maternal age, new medical disorders in pregnancy, increasing patient knowledge and demands, greater focus on preconception care, changes in antenatal care models and testing, rising rates of caesarean sections and complications like placenta accreta, and the growth of fields like fetal medicine. The practicing obstetrician must continue adapting to ongoing changes in the field.
Oral contraceptive pills (OCPs) contain synthetic hormones, usually a combination of estrogen and progestin, that prevent pregnancy through multiple mechanisms. They work by inhibiting ovulation, thickening cervical mucus, and thinning the uterine lining. Common estrogen and progestin components include ethinyl estradiol and levonorgestrel. OCPs are generally safe and effective when used correctly, with failure rates around 0.1% per year. They also provide non-contraceptive benefits like reducing menstrual cramps and risk of certain cancers. Doctors should screen for contraindications before prescribing OCPs.
This document discusses renal diseases in pregnancy. It begins by noting that urinary tract infections are common in pregnancy and can cause maternal and fetal complications. It then discusses how renal disease can be a risk factor for preeclampsia and fetal growth restriction. The document provides details on renal adaptation during pregnancy, management of urinary tract infections and pyelonephritis, renal stones, and the effects of pregnancy on pre-existing renal impairment. It emphasizes the importance of pre-pregnancy counseling and management for women with renal disease.
1) Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation therapy that can range from mild to severe or even life-threatening. It is characterized by ovarian enlargement and fluid shift into the body's tissues.
2) Risk factors for OHSS include high AMH levels, PCOS, previous OHSS, and high follicle counts and estrogen levels during treatment. Clinicians must monitor for OHSS and be prepared to manage it.
3) Management strategies aim to prevent OHSS through individualized protocols, or to treat symptoms by delaying hCG, using lower hCG doses, cryopreserving all embryos, or cancelling cycles if needed. Secondary prevention after trigger includes
This document discusses the many non-contraceptive benefits of combined oral contraceptives (COCP). It notes that 33% of adolescents using COCP do so for non-contraceptive reasons approved by research. COCP can effectively treat conditions like dysmenorrhea, dysmenorrhea, signs of androgenization, PMS, ovarian cysts, endometriosis, adenomyosis, myoma, and others. It discusses the mechanisms by which COCP provides these benefits and provides evidence from multiple studies. The document emphasizes that understanding these non-contraceptive benefits can enhance healthcare providers' care of patients.
This document discusses ectopic pregnancy, which occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tubes. It details the risk factors, symptoms, diagnostic process, and management options for ectopic pregnancies. Management may involve expectant monitoring, medical treatment with methotrexate, or surgical intervention depending on the individual case. Proper treatment is important to preserve future fertility and prevent life-threatening complications from tubal rupture.
This document discusses ectopic pregnancy, providing definitions and discussing incidence, etiology, clinical presentation, investigations, management of pregnancy of unknown location, and treatment approaches. Some key points:
- Ectopic pregnancies occur when implantation occurs outside the uterus, most commonly in the fallopian tubes. Risk factors include pelvic infections, previous ectopic pregnancies, and tubal damage.
- Patients often present with abdominal pain and vaginal bleeding. Diagnosis involves transvaginal ultrasound, serum hCG levels, and ruling out intrauterine pregnancy.
- Pregnancies of unknown location require serial hCG measurements and potentially endometrial biopsy to determine pregnancy location when ultrasound is inconclusive.
This document discusses early pregnancy bleeding and differentials, implantation in early pregnancy, ultrasound findings, miscarriage definitions and management options, ectopic pregnancy risk factors and treatments, and recurrent miscarriage evaluation. It defines miscarriage as loss of intrauterine pregnancy before 24 weeks and describes expectant, medical, and surgical management options. For ectopic pregnancies, it notes fallopian tubes as the most common site and lists risk factors. Treatment may involve methotrexate or laparoscopic salpingectomy.
This document summarizes the clinical manifestations, diagnosis, and management of ectopic pregnancies. Ectopic pregnancies occur when a fertilized egg implants outside the uterus, usually in a fallopian tube. Diagnosis is based on quantitative hCG levels and transvaginal ultrasound findings. Treatment options include expectant management for very low-risk cases, systemic methotrexate or surgery. Surgical options include salpingostomy to remove the ectopic pregnancy or salpingectomy to remove the fallopian tube. Close monitoring of hCG levels is important after any treatment.
Ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tubes. It accounts for 1-2% of pregnancies and risk factors include previous pelvic inflammatory disease, IUD use, infertility, and smoking. Clinical features range from asymptomatic to acute abdominal pain and vaginal bleeding. Transvaginal ultrasound and quantitative beta-hCG levels are used to confirm the diagnosis. Treatment options include surgical removal by laparoscopy or laparotomy, or medical management with methotrexate depending on the stability of the patient. Expectant management may be considered for some stable cases. Ruptured ectopic pregnancies require emergency surgery and blood transfusions to stabilize the patient.
An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in one of the fallopian tubes. Risk factors include previous ectopic pregnancy, pelvic inflammatory disease, IUD use, and infertility treatments. Ectopic pregnancies are diagnosed through transvaginal ultrasound, serum hCG and progesterone levels, and sometimes laparoscopy. Treatment options include expectant management for very early ectopic pregnancies, systemic methotrexate injections to terminate the pregnancy, or surgery to remove the ectopic pregnancy if it has ruptured or growth is threatening rupture. Methotrexate treatment involves either a single dose or two doses of the drug followed by monitoring of hCG levels.
Gestational trophoblastic disease (GTD) is a spectrum of conditions arising from abnormal placental trophoblast proliferation. It includes hydatidiform moles (complete and partial), which are benign, and gestational trophoblastic neoplasia (GTN), which includes invasive mole, choriocarcinoma, and other rare types, that are malignant. Complete moles are diploid and result from fertilization of an empty ovum, while partial moles are triploid/tetraploid arising from dispermic fertilization of a normal ovum. Diagnosis is based on clinical exam, serum hCG levels, ultrasound findings, and histology. Treatment of molar pregnancies involves suction dilation
Endometrial hyperplasia is an abnormal overgrowth of the endometrial lining that can progress to cancer if left untreated. It is classified as either without atypia or with atypia based on presence of cell abnormalities. Treatment involves identifying risk factors like obesity and treating with progestogen therapy. For hyperplasia without atypia, the levonorgestrel IUD is first-line treatment for 6 months followed by surveillance. Hysterectomy may be considered if treatment fails or for atypical hyperplasia. Close monitoring is important to detect progression or recurrence of the condition.
Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception. In gestational trophoblastic disease (GTD), a tumor develops inside the uterus from tissue that forms after conception (the joining of sperm and egg).
Gestational trophoblastic disease (GTD) includes hydatidiform moles, benign lesions, and gestational trophoblastic neoplasms. Complete and partial hydatidiform moles are abnormal pregnancies characterized by placental abnormalities. Diagnosis involves clinical assessment, histopathology, and tumor marker testing. Treatment ranges from surgical evacuation to multi-agent chemotherapy depending on disease extent and prognosis. Long-term follow up is important due to risk of persistent or recurrent GTD. Gestational trophoblastic neoplasia can develop after molar or non-molar pregnancies and may metastasize, requiring more intensive treatment. Precise classification, staging, and risk stratification guide personalized management of GTD
This document discusses venous thromboembolism (VTE) in pregnancy. It notes that VTE is more common in pregnant women than non-pregnant women, with an incidence of 85/100,000 pregnancies. Risk factors include blood group A, multiple pregnancy, cesarean delivery, and increased age or BMI. Diagnosis involves ultrasound or CT scans, with D-dimer testing not recommended. Treatment involves low molecular weight heparin until diagnosis is ruled out. Specialist obstetric clinics are available at King's Hospital for conditions like preeclampsia, liver disease, rheumatology and more.
This document discusses the medical management of ectopic pregnancy. It begins by defining ectopic pregnancy and listing some key statistics. It then covers pathogenesis, risk factors, signs and symptoms, differential diagnosis, diagnostic tools including quantitative beta-hCG and ultrasound findings. Management options are expectant monitoring, surgical intervention, or medical treatment with methotrexate, with specific criteria outlined for each approach. Complications of untreated ectopic pregnancy like tubal rupture are also noted.
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes. Risk factors include age over 35, previous pelvic or abdominal surgeries, STDs, and fertility treatments. Symptoms can include abdominal pain, vaginal bleeding, and shoulder pain. Diagnosis involves testing hCG levels in blood and transvaginal ultrasound. Treatment options are medication with methotrexate or laparoscopic surgery to remove the embryo and repair any damage, as rupture can cause life-threatening bleeding.
Early pregnancy loss by dr alka mukherjee dr apurva mukherjee nagpur ms indiaalka mukherjee
Early pregnancy loss, or loss of an intrauterine pregnancy within the first trimester, is encountered commonly in clinical practice. Obstetricians and gynecologists should understand the use of various diagnostic tools to differentiate between viable and nonviable pregnancies and offer the full range of therapeutic options to patients, including expectant, medical, and surgical management.
Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation 1. In the first trimester, the terms miscarriage, spontaneous abortion, and early pregnancy loss are used interchangeably, and there is no consensus on terminology in the literature.
This document discusses obstetric embolism, including amniotic fluid embolism (AFE) and venous thromboembolism (VTE). It provides data on maternal deaths in Malaysia from these causes from 2006-2012. It also outlines risk factors for VTE in pregnancy, signs and symptoms, diagnostic methods, and treatment guidelines involving low molecular weight heparin, unfractionated heparin, or warfarin. Strategies to reduce VTE risk include modifying risks factors before pregnancy, awareness and guidelines, and risk-based management during pregnancy and postpartum.
Pathophysiology and epidemiology
Implantation of a fertilised egg outside of the uterus. Almost uniformly unviable.
Affects 1/100 pregnancies.
98% are tubal, usually in the ampulla. Remainder are in the ovaries, cervix, and peritoneum, the latter sometimes carrying to the 3rd trimester.
Eventually, trophoblast invasion of the tubal wall can cause tubal rupture and potentially major haemorrhage. However, many cases resolve spontaneously without rupture.
Presentation
Typical presentation:
Patients usually present 6-8 weeks after last period, though 30% present before a missed period.
Common symptoms are PV bleeding (dark or fresh) – which can occur with or without rupture – and/or abdominal or pelvic pain. However, many patients are asymptomatic.
Other possible features:
Syncope and dizziness.
Shoulder tip pain.
Painful defecation and urination.
Diarrhoea and vomiting.
Adnexal mass or big uterus.
Cervical excitation
Sudden rupture: peritonism and shock.
early pregnancy bleeding/ miscarriage types and management.Haneen Hassan
Early pregnancy bleeding is defined as vaginal bleeding before 20 weeks of gestation. Potential causes include local issues like polyps or cervical ectropian, as well as miscarriage, ectopic pregnancy, or molar pregnancy. Miscarriages are categorized as threatened, inevitable, incomplete, complete, or missed based on symptoms and exam findings. Treatment depends on the type but may include expectant management, medical management with drugs like misoprostol, or surgical evacuation of the uterus. Recurrent miscarriage is defined as 3 or more losses and has causes like genetic issues, anatomical abnormalities, blood clotting disorders, endocrine issues, or immunological factors.
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4. • Implantation bleeding.
• Pregnancy of unknown location (PUL).
• Miscarriage.
• Ectopic pregnancy.
• Gestational trophoblastic disease (GTD).
• Genital tract pathology (e.g. polyp, ruptured
varicose veins and malignancy).
Causes of bleeding in early pregnancy
Dr Mostafa Darweish
4
5. • Despite improvements in diagnosis and management,
ruptured ectopic pregnancy continues to be a significant
cause of pregnancy-related mortality and morbidity.
• In 2011–2013, ruptured ectopic pregnancy accounted for
2.7% of all pregnancy-related deaths and was the leading
cause of hemorrhage-related mortality.
• Every sexually active, reproductive-aged woman who
presents with abdominal pain or vaginal bleeding should
be screened for pregnancy, regardless of whether she is
currently using contraception.
Ectopic Pregnancy
Dr Mostafa Darweish
5
9. β-hCG levels : Sub-optimal:
= 3 measurements showing:
-Suboptimal increase OR
-Suboptimal decrease OR
-Flactuating OR
-Plateauing.
-When the rise or the fall in β-hCG is sub-optimal the
cause may be:
-Persisting PUL.
-ECTOPIC pregnancy .
Dr Mostafa Darweish
9
10. • If β-hCG is above the (DZ) and no “true"
gestational sac is seen inside the uterus by TVS,
ectopic pregnancy is highly likely.
• If a gestational sac is clearly identified within the
uterine cavity, it is unlikely that an ectopic
pregnancy coexist (heterotopic pregnancy).
• However, it should be considered in all women
presenting after IVF.
β-hCG levels : Sub-optimal
Dr Mostafa Darweish
10
11. • Ectopic pregnancy
• The initial serum β-hCG level is a key
prognostic indicator for the success of
management in cases tubal ectopic
pregnancies.
• TVS is the diagnostic tool of choice ectopic
pregnancy.
• Laparoscopy is no longer the gold standard
for diagnosis. Dr Mostafa Darweish
11
12. • TYPES OF ECTOPIC PREGNANCY:
• The majority (~95%) of ectopic pregnancies occur
in the Fallopian tube (tubal ectopic pregnancy).
• An ectopic pregnancy may occur in "a non-tubal"
location, in conjunction with an IU pregnancy, or
even bilaterally.
• Uncommon types include heterotopic, cesarean
scar, cervical, ovarian, rudimentary uterine horn,
and abdominal pregnancy. Dr Mostafa Darweish
12
13. • Tubal ectopic
• TVS diagnostic criteria on:
• The following may be visualized:
• (1) An “inhomogeneous” adnexal mass.
• (2) An empty extra-uterine sac with a
hyper-echoic ring.
• (3) A yolk sac and/or fetal pole with or without
cardiac activity in an extra-uterine sac.
Dr Mostafa Darweish
13
14. • US
Tubal ectopic:
• An inhomogeneous mass may represent either
an early developing ectopic (before a gestational
sac is visualized) or a failing ectopic pregnancy.
Dr Mostafa Darweish
14
15. DIAGNOSIS OF ASYMPTOMATIC TUBAL PREGNANCY
Not all of ectopic pregnancies can be visualized
initially on TVS and indeed, some are never
visualized at all.
• Possible ectopic pregnancy.
• Probable ectopic pregnancy.
• Ectopic pregnancy.
Dr Mostafa Darweish 15
16. • Treatment Options For Tubal Ectopic Pregnancy:
• 1-Expectant management:
• At least 15% of ectopic pregnancy resolves spontaneously
without any intervention.
• Repeat β-hCG tests: between 2 and 7 days.
• A rapidly decreasing β-hCG level predicts a favourable outcome.
• Followed up until the serum β-hCG level was < 10 mIU/ml.
Surgical Management:
Indications for surgical treatment include:
Hemodynamic instability.
Failed medical (pharmacological) therapy.
Coexisting heterotopic pregnancy.
Patient not able to comply with follow-up.
Dr Mostafa Darweish
16
17. • 2-Pharmacological Management:
• Systemic methotrexate is the most commonly used drug
for treatment of tubal ectopic pregnancy.
• “Anti-metabolite" chemotherapeutic agent.
• Folic acid antagonist.
• Therefore, it inhibits DNA synthesis and cell
reproduction, primarily in actively proliferating cells
such as malignant cells, trophoblasts, and fetal cells.
• Adverse reactions to MTX include stomatitis and
conjunctivitis.
• Gastritis, enteritis, dermatitis, pneumonitis, alopecia,
elevated liver enzymes, and bone marrow suppression.
Dr Mostafa Darweish
17
18. • Indications of "MTX" treatment:
• Systemic methotrexate has been used to treat
gestational trophoblastic disease since 1956 with
excellent results and was first used to treat
ectopic pregnancy in 1982.
• "MTX" is indicated for treating asymptomatic
patients having ‘persisting PUL’ or tubal ectopic
pregnancy with special criteria.
• MTX has been reported to be successful in
treating interstitial, abdominal, and cervical
pregnancies, which have high substantial surgical
risk. Dr Mostafa Darweish
18
20. • A Good Candidate For Methotrexate:
• The patient prefers medical option, willing to attend
follow-up for up to 6 weeks, not breast-feeding,
haemodynamically stable, and having no severe medical
conditions including renal or hepatic disease,…..
CRITERIA OF ECTOPIC PREGNANCY ( for MTX
treatment):
Minimal clinical symptoms.
No evidence of tubal rupture.
Mass : < 3.5 cm.
No cardiac pulsation.
β-hCG level is < 3,000 mIU/mL ( 1500: 3000).
No contraindications to Methotrexate.
Patient will be available for follow-up.Dr Mostafa Darweish
20
21. • MTX
• There are many well-documented cases of women with
IU pregnancies treated for suspected ectopic pregnancy
with MTX.
• MTX should, therefore, never be given at the first visit,
unless the diagnosis of ectopic pregnancy is absolutely
clear and a viable ‘IU pregnancy’ has been excluded.
RCOG
• If the concept of the β-hCG discriminatory level is to be
used as a diagnostic aid in women at risk of ectopic
pregnancy, the value should be conservatively high
(e.g., as high as 3,500 mIU/mL) to avoid the potential
for misdiagnosis and possible interruption of an
intrauterine pregnancy. Dr Mostafa Darweish
21
23. • The Single Dose Protocol
• Request:
• Serum β-HCG level, blood type, CBC, renal
function tests, liver function tests.
• "MTX" is rapidly cleared from the body by the
kidneys, and in women with renal insufficiency,
a single dose of MTX can lead to death or severe
complications, including bone marrow
suppression, acute adult RDS and bowel
ischemia.
• NB. dialysis does not provide normal renal clearance.
Dr Mostafa Darweish
23
24. • Single-dose protocol
• MTX can be given IV, IM, or orally or by direct
local injection into the ectopic pregnancy sac
transvaginally or laparoscopically.
• IM administration is most common.
• Approximately 15 to 20% of women will require
a second dose of MTX and fewer than1% of
patients need more than two doses. Dr Mostafa Darweish
24
25. • Single-dose protocol
• “Day 1" is the day that MTX is administered.
• The dose of MTX used to treat ectopic pregnancy is 50
mg per square meter of body surface area "50 mg/m2”
• Frequently, an increase in β-hCG level may be observed
in the first several days after therapy (due to continued
production of β-hCG by the syncytiotrophoblast).
• Additionally, 60% of patients experience
increased pelvic pain (may be due to tubal
abortion or haematoma formation causing tubal
distension). Dr Mostafa Darweish
25
26. • Single-dose protocol
• *On Day 7
• Administer a second dose of MTX if the serum β-hCG
concentration has not declined by at least ‘25%’ from
the day 1 level.
• After day 7, β-hCG testing is repeated weekly.
• If there is a ≥15% β-hCG decline from days 7 to 14, check
β-hCG weekly until the level is undetectable.
• NB. The β-hCG concentration usually declines to <15
mIU/mL by 35 days post-injection, but may take as long
as 109 days. Dr Mostafa Darweish
26
27. • Single-dose protocol
• *On Day 14,
• If there is a <15% β-hCG decline from days 7 to 14,
a third dose is given IM.
• Give a maximum of three doses of MTX.
• If hCG levels plateau or increase during follow-up,
consider administering methotrexate for treatment of a
persistent ectopic pregnancy.
• If the β-hCG falls <15% between weekly
measurements after a third dose, surgery is
indicated . Dr Mostafa Darweish
27
28. • The two-dose regimen was first proposed in 2007 in an
effort to combine the efficacy of the multiple-dose
protocol with the favorable adverse effect profile of the
single-dose regimen.
• The two-dose regimen adheres to the same hCG
monitoring schedule as the single-dose regimen, but a
second dose of methotrexate is administered on day 4 of
treatment.
• If hCG levels plateau or increase during follow-up,
consider administering methotrexate for treatment of a
persistent ectopic pregnancy.
Two-dose protocol
Dr Mostafa Darweish
28
29. • III- Fixed Multiple-Dose Protocol :
• The multiple-dose MTX regimen involves up to 8
days of treatment with alternating administration
of MTX and folinic acid, which is given as a rescue
dose to minimize the adverse effects of the
methotrexate. Dr Mostafa Darweish
29
30. • III- Fixed Multiple-Dose Protocol :
• Administer ‘MTX’ 1 mg/kg IM on days 1, 3, 5, 7; alternate
with folinic acid 0.1 mg/kg IM on days 2, 4, 6, 8.
• Measure β-hCG levels on ‘MTX’ dose days and continue
until β-hCG has decreased by 15% from its previous
measurement.
• If the decrease is greater than 15%, discontinue
administration of ‘MTX’ and measure hCG levels weekly
until reaching non-pregnant levels (may ultimately need
one, two, three, or four doses)
• If hCG levels plateau or increase during follow-up,
consider administering methotrexate for treatment of a
persistent ectopic pregnancy. Dr Mostafa Darweish
30
31. • Single-Dose Versus Two-Dose:
• A systematic review and meta-analysis of three
randomized controlled trials showed a
comparable risk of adverse effects for the two-
dose and single-dose protocols.
• A systematic review and meta-analysis of three
randomized controlled trials .
• Single-Dose Versus Two-Dose.
• Single-Dose Versus Multiple-Dose.
Choice of MTX protocol
Dr Mostafa Darweish
31
32. • Single-Dose Versus Two-Dose:
• The two-dose regimen was associated with
greater success among women with high initial
β-hCG levels.
• A statistically significant higher success rate was
reported for the two-dose regimen versus the
single-dose regimen in patients with initial serum
hCG levels between 3,600 mIU/mL and 5,500
mIU/mL Dr Mostafa Darweish
32
33. • Relative contraindications for the use of MTX do
not serve as absolute cut-offs but rather as
indicators of potentially reduced effectiveness.
• For example, a high initial hCG level is considered
a relative contraindication.
• Systematic review evidence shows a failure rate of
14.3% or higher with MTX when pretreatment
hCG levels are > 5,000 mIU/mL compared with a
3.7% failure rate for hCG levels < 5,000 mIU/mL.
Dr Mostafa Darweish
33
34. • Single-Dose Versus Two-Dose
• Resolution of serum β-HCG levels after medical
management is usually complete in 2–4 weeks
but can take up to 8 weeks.
• The resolution of hCG levels is significantly faster
in patients successfully treated with the two-
dose methotrexate regimen compared with the
single-dose regimen. Dr Mostafa Darweish
34
35. • Single-Dose Versus Multiple-Dose
• Observational studies that compared the single-
dose and multiple-dose regimens have indicated
that although the multiple-dose regimen is
statistically more effective the single-dose
regimen is associated with a decreased risk of
side effects. Dr Mostafa Darweish
35
36. • The choice of methotrexate protocol should be
guided by the initial β-hCG level and discussion
with the patient regarding the benefits and risks
of each approach.
• In general, the single-dose protocol may be most
appropriate for patients with a relatively low initial β-
hCG level or a plateau in β- hCG values, and the two-
dose regimen may be considered as an alternative to
the single-dose regimen, particularly in women with an
initial high β-hCG value.
Choice of MTX protocols
Dr Mostafa Darweish
36