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Essay 368 - Ectopic pregnancy

Essay 368 - Ectopic pregnancy Posted by Farrukh G.

A healthy 32 year old woman presents with a blood-stained vaginal discharge 7 weeks after her last menstrual period. She is found to have a left tubal ectopic pregnancy. (a) Discuss the criteria for medical management of ectopic pregnancy [5 marks]. (b) Describe how you will undertake medical management of ectopic pregnancy given that these criteria are met [15 marks].

answer essay 368 Posted by Gajendran K.

(a)The criteria for medical management includes a unit which has a proper treatment protocol and facilities for follow up and the patient should also receive some written information about the possible need for future treatment and adverse outcome that could occur .The patient should also be able to return easily for assessment anytime during the follow-up. The patient also has to be  hemodynamically stable  .The b-hcg should be less than 3000 iu/l and she has only mild symptoms. The ectopic pregnancy should also not be viable that means no presence of cardiac activity .

(b) At day of administration , certain baseline blood investigations such as full blood count , urea and electrolytes and liver function test should be taken . blood also should be grouped and saved. The b-hcg levels should also be taken for monitoring of the response .Then  i would adminster intramuscular methotrexate 50mg/m2 after reviewing the baseline investigations and making sure that it is normal. The b-hcg may rise between day 1 - day 4 , hence therefore i would measure the b-hcg at day 4 and day 7 of administration. however if she  experiences any increase in abdominal pain or distension she should be advised to seek medical attention immediately as there is a risk of tubal rupture .

B-hcg levels are taken as mentioned in day 4 and day 7 , and if there is a decrease of more than 15%  between this period , her b-hcg should monitored weekly until it reduces to 10iu/l which might take up an average of a month .  If the decrease is less than 15% , then a repeated dose of intramuscular methotrexate ( 50mg/m2) should be given after repeating the baseline blood investigation and making sure it is normal.  Less than 10% of women may still have their b-hcg levels persisting after this and may require surgical intervention .

women should also be advised that they may experience some abdominal pain and should seek medical attention if they are worried. They should be advised against sexual intercourse during treatment and should take a lot of fluids and have reliable contracpetion for at least 3 months from last dose of methotrexate as there is a risk of teratogenicity.

essay368 Posted by sujata B.

 

1. The critrria for medical management of tubal pregnancy are that the woman should be haemodynamically stable, with a bHCG value of less than 3000 iu/l,an ultrasound showing that the mass is <3cm, no cardiac activity and with minimal fluid in the pouch of douglas. The woman should be compliant to treatment and follow ups. The woman should not have any contrindicating factors like liver imparement  for methotrexate therapy.
 
2.I will first counsel the patient, regarding the treatment which involves ging a chemotherapeutic drug which will destroy the functioning trophoblastic tissue and bring down the HCG levels.Hospital stay would be required and I will also explain to her that the chances of rupture while on treatment is 7%, a second injection in 15% cases, a repeat ectopic  8%, and that there is an 80% chance of tubal patency, and a 55% chance of subsequent  intrauterine pregnancy.I will take an informed consent. Once admitted I will do her blood tests-FBC,LFT,GRP & SAVEI will give her a dose of Methotrexate of 50 mg I/M. I will repeat her bHCG on day4 and again on day 7.I will give her a second dose of methotrxate if the level has not decreased by 15% from the day4 value. While in hiospital I will monitor her vitals, and reasses if she has complaints of acute pain or fainting attack to rule out rupture. I will discharge if stable and with evidence that the bHCG levels are decreasing,I will discharge when the levels have come dwn to <1500 iu/l. I will give her an information leaflet on indications for immedite reporting to hospital,  like features of acute pain.,or fainting attack. I will advice her not to resume sexual activity not to use tampons,. I will give her contact number of the hospital emergency, and that of the healthcare personell attending to her.
The bHCG levels will be checked weekly till it comes down to 20iu/l. I will give her contraceptive advice and explain to her that methotrexate can .have a teratogenic effect till 3 months after treatment
Posted by Hala A.
1) clinical criteria would be that the patient should be asymptomatic with no signs of rupture with BHCG of less than 3000iu. Ultrasound findings would be ectopic mass with no fetal heart ( not live ectopic) and very minimal fluids in Pouch of Douglas. Medical management should be offered at a hospital that can provide easy accessibility and with known protocol to follow patients with BHCGs and ultrasound . Patient should be aware when to call to the hospital and what symptoms to expect as over 30% will have abdominal pain and 10% will have tubal rupture.. Methotrexatewhich is digger folate reductase inhibitor is the treatment of choice of medical management of ectopic pregnancy and it is given in a dose between 70-90 mg based in surface area of the patient ( 50mg/ 1.3m) . Usually one dose would be enough but 14% of patients might require a second dose. Follow up BhCG on day 4 and day 7 after methotrexate administration. BHCG should fall by 15%. There is 7% chance surgical route might be needed if patient is becoming symptomatic with signs of ectopic rupture clinically and on ultrasound. Patient should be encouraged to increase their fluid intake and avoid sexual intercourse during the treatment period. Side effects such mouth ulcers stomittis and abdominal pains warrants seeking a medical attention. Patient should take effective contraception for 3 months after methotrexate. Patient should be counseled about the risks and benefits of the medical managment, advised when ro come to the hospital and informed consent should be obtained. Agreed protocol in the department which is accessible to the patient all the time and 24 contact service and Leaflets should be provided for the patient.
essay 368 answer Posted by mariam M.

A candidate for medical management should meet the following criteria. She shoud be haemdynamically stable.Also no severe or persistant abdominal pain. B-hcg levels less than 300iu.Fetal pulsation should be absent. There should be no more than a small amount of free fluid on the ultrasound. The patient should be able and stuck to follow up until the ectopic pregnancy has resolved .Selection of the patient is important as medical treatment is by methotrexate a folic acid antagonist it should not be used in certain patient .FOR EXAMPLE it is contra indicated where there intra uterine pregnancy or the women is breast feeding. Alcoholics and those who are immunodeficent are contraindicatins. Those who have active pulmonary disease or peptic ulcer should not use methotrexate.Known having blood dyscrasia or hepatic or renal dysfunction are contraindicated to the use of methotrexate .We should not forget those who refuses blood transfusion.                                                                                                                                                                    ( B)                                                                                                                                                                                                                                                Iwill give the women written information about the  need for further management , and the side effect of the treatment .Prior to the first dose iwill  screen the women with BHCG to rule out spontaneous abortion , acomplete blood count .I Will do blod group and RH cause women may need anti d if resus negative .Iwill do renal function tests and liver function tests as methotrexate is metabolized by the liver and excreated by the kidnies ..Iwill do chest x ray to those who have ahistory of pulmonary disease. Initial dose will be MTX 50mg/m2  intra muscular. Side effects include, nausea, vomiting, gastric upset and fatigue (common).Most patient will suffer from abdominal pain .Serious and rare side effect is bone marrow suppression .Also rare reversible alopecia ,pneumonitis            .Treatment may cause increase in the abdominal girth. Bhccg shoud be repeated on day 4 and 7 ,looking for adrop of 15% between these results .Asecond dose will be required if the BHCG drops by less than15%.    Iwill tell my patient to avoid intercourse until hcg is undetectable Iwill avoid pelvic exam and ultrasound duringMTX therapy.Iwill advice her to avoid sun exposure to limit risk of MTX dermatitis.Also iwill advice her to avoid foods and vitamins containing folic acid.                                                                                                                           Iwill measure HCGserially at weekly at weekly interval to ensure that concentrations decline steadily and be come undetectable Complete resolution usually takes2-3 weeks. When declining levels again rise , the diagnosis of persistant ectopic is made. After resolution patien can get pregnancy after 3 months if single dose ,and after 6months if dose repeated as there is a risk of teratogenicit

essay 368 Posted by Anagha W.

a) Medical management of ectopic pregnancy involves the use of methotrexate. The criteria for selection of women for medical management of ectopic pregnancy are based on the technique being safe and likely to be effective. The greentop guideline states that medical management can be offered to women with serum B-HCG level of less than 3000 IU/L, who are clinically stable and will comply with follow up. So it should be ensured that she understands the implications of the treatment and the terms of follow up based on the hospital protocol. The data on size of the ectopic mass is inconclusive. The larger the mass, the more likely it is to rupture. Some clinicians use 4 centimetre as a cut off for the size of the ectopic pregnancy. The woman should have minimal symptoms. Presence of foetal cardiac activity is likely to increase the chance of failure; hence absent foetal cardiac activity is preferred for medical management of ectopic pregnancy. In addition, she should have no contraindication to the use of methotrexate like renal impairment, hepatic dysfunction, current breast feeding status and concurrent intrauterine viable pregnancy as in heterotopic pregnancy.

 

b) Methotrexate is administered as a single dose 50mg/square metre of body surface area, intramuscular injection on an outpatient basis. Following this serum BHCG should be checked on day 4 and day 7 of the injection. There should be a decline of more than 15%; otherwise the dose of methotrexate should be repeated. With appropriate decline in serum BHCG, the levels must be repeated according to the hospital protocol till complete resolution. The woman should be informed that there is about 7 % chance of tubal rupture in which case she will require further treatment. 75% women will experience pain, most of which is due to tubal abortion. However she may require admission to hospital for observation to distinguish between tubal abortion and tubal rupture. She should be advised to take ample fluids during the treatment and avoid dehydration. She may experience toxic side effects of methotrexate like alopecia, gastrointestinal upset with nausea, stomatitis and conjunctivitis. She should be reassured that these side effects are short-lived. She should be advised to avoid sexual intercourse during the treatment and to use effective contraception for 3 months after the treatment as methotrexate is highly teratogenic. She will need administration of anti-D immunoglobulin if she is nonsensitized rhesus negative and should be counseled accordingly.  All verbal information should be backed by clear written information in the form of leaflets/websites. She must also be given a 24 hour local contact number in case of an emergency.

 

essay 368 Posted by maged  E.

A) the patient shuuld be heamodynamically stable with mild to moderate symptoms, ectopic should be<2cm ,BHCG <3000 IU, fluid in douglas pouch <100ml, with no fetal heart beat & the patient is capable of compliance with follow up with easy access to hospital at any time shuold the need arise.

B)

answer - ectopic pregnancy Posted by preetiba rani V.

a)  Medical management of ectopic pregnancy should be offered to suitable women in a unit that has a proper treatment and close follow up protocol.  The woman must be able to comply with the treatment and subsequent close follow up.  She must also be able to easily return for assessement.  Ultrasound assessment should not have fetal cardiac activity in the site of ectopic.  The initial beta HCG must be less than 3000 IU/L

b)  Medical management starts with a proper counselling with clearly written information regarding treatment, further follow up and assessment and possible complications associated with it.  Administration of intramuscular methotrexate must be calculated per body surface area.  A transient increase in beta HCG may occur between Day 1 and Day 4 of treatment in 85% of women.  A serum beta hcg is then monitored on Day 4 and Day 7 of treatment.  If the HCG levels fall less than 15% a further dose of IM Methotrexate is needed. The woman must be advised to avoid sexual intercourse and have plenty of fluid intake.  The use of reliable contraception for 3 months following methotrexate treatment is important as there is a possibility of terotogenic effetcs of methotrexate. During the follow up, assessment must also be done to look for complications associated with methotrexate treatment.  This includes stomatis, ulcers and in the oral cavity, alopecia, pneumonitis (suggested by fever, cough or shortness of breath).  If such complications occur a full blood count need to be taken to look for neutropenia.  Abdominal pain also is a common complaint (75%) which can be confusing.  This is because 7% of women may experience tubal rupture during follow up.  If the woman complaints of abdominal pain a thorough assessment is needed to exclude tubal rupture.  In such events medical treatment has to ba witheld and a laparoscopy needs to be carried out if she is haemodynamically stable

essay 368 Posted by maged  E.

B)

Methotrexate is the drug of choise given in single dose better than multiple ones as it is cost effective &less side effects.

Before start of treatment patient should be councelled as regards side effects (mucositis &GIT upset) advantage (outpt treatment, avoidance of surgical intervention & admission in majority of cases,85-95% success rate, and comparable results to laparoscopy) and disadvantage (abdominal pain 75%, possible failure of treatment with need for surgical intervention 10%, possible need for furthure dose,&the need for follow up & investigation).

BHCG should be measured at start ,day 4,7 of treatment.. If level of BHCG failed to decrease by 15% on day 4-7 further dose should be given .Renal function tests &Lfts shuold be checked before treatment.

instruction given to patient as regard avoidance of sexual intercourse during treatment ,mentain ample fluid intake & to seek medical help if severe abdominal pain develops. she should avoid pregnancy for 3 month after treatment for possible teratogenic effects of Methotrexate.

If patient develops severe abdominal pain admission should be considerd, keep her under observation check vitals . Pain could be d.t. tubal rupture or tubal abortion & it is difficult to distinguish between them. ultrasound may help eo exclude massive intraperitoneal bleeding &the need for surgical intervention.

 

Posted by uzma sultana M.

A] The criteria for medical management of ectopic pregnancy first depends on the patient  selection , A haemodynamically stable patient ,  BHCG level <3000 iu ,  Gestation sac <3 cm  , Absence of fetal cardiac activity ,  The patient should have easy accessability to the hospital in case of emergency bleeding and abdominal pain ,  She should be provided with hospital  telephone service for 24 hrs ,  The patient should not have Hepatoma  and not be in immunocompromised state for the use of methotrexate .  Information leaflet and contact of support group should be provided .

B] After the patient selection , adequate counselling must be done about the benefits and risk of medical treatment  , The patients wishes must be given due consideration ,  Take consent and provide information leaflet and contact of support group ,  Follow the unit protocol for  medical management   of ectopic pregnancy ,

The benefits of medical management are  , Risk of exposure to anaesthesia and  surgical risk is not there , Risk of Haemorrhage and Blood transfusion is not there  , it is less expensive ,  Reccurrance is less and intrauterine pregnancy rate is more .

The disadvantages are ,  There is prolonged follow up before resolution of pregnancy occurs  , Patient is anxious and mentally disturbed ,  Risk of bleeding in case of ruptured tube and haemorrhage which needs Blood transfusion   and emergency surgical intervention  , Fear of future fertility .

The patient is admitted in hospital for atleast 48 hrs  during the treatment  in case of emergency bleeding and abdominal pain ,

Investigations such as FBC, Haemoglobinopathy, Blood group and save , Rhesus status, LFT, Urea and creatinine level must be done.

Temperature ,BP, Pulse is recorded  , Injection Methotrexate 50 mg per square meter is given by intramuscular route  , Following this,   The patient might have abdominal pain after 3 days,    side effects such as nausea, vomiting, and diarrhoea , throat ulceration might be there ,  Folinic acid might be given for the side effects  , Then do serum BHCG on the 3 rd and 7 th day to see for resolution of the pregnancy ,  if the level of Bhcg is <15% then the treatment is successful  .  Following this do weekly  BHCG until the level is < 20 iu  . If the BHCG is > 15% then  repeat  Methotrexate after 1 week and follow the schedule until BHCG is < 20 iu .  During the treatement , Advice the patient to avoid sexual intercourse and drink adequate fluids and use contraception for 3 months to prevent methotrexate teratogenicity .   Anti D immunoglobilin of dose 250 iu  is given for Rhesus negative patient .

In some cases there will be tubal rupture and patient  will be haemodynamically unstable  and needs emergency surgical intervention  such as laparotomy or laparoscopic salphingectomy   and blood transfusion ,  provided expert is available for laproscopic intervention .

Postpartum , follow up appointment is given ,  contraception advice is given  for at least 3 months to prevent  methotrexate teratogenicity  , All the details are documented in the notes and information leaflet and support group contacts are given .

Posted by Nabila A.

A)1.The criteria for medical management are careful selection of the woman who are haemodynamically stable ,do not have pelvic pain or tenderness.

2.On transvaginal ultrasound ther e should not be any  fetal cardiac activity ,unruptured ectopic mass <3.5 cm as well as no fluid in the pouch of douglus.

3.She agrees to use contraception  for three months after the treatment.

4.She has  been  fully counseled to undergo medical management as well as motivated to comply with the  close follow up.They should have easy access to the hospital for  follow up.

5.The initial HCGlevels  should be  less than 3000 iu/l.

6.Methotrexate  administration is not contraindicated(deranged  liver and renal function testsor bone marrow  impairment.

7.no pre existing severe medical disorder

8.not breastfeeding

9.do not have a preexisting intrauterine pregnancy
 

B)The management should be carried out by dedicated Early pregnancy units with the facility of SerialHCG measurements and transvaginal  scan.Units should have treatment  and follow up protocols for use of  methotrexate.

Explain the treatment  to women and her partner with written information about the advantages and disadvantages of methotrexate,its success rate including contact details of EPAU  andemergency care  contact .

Pre treatment bloods are  collected(Full blood count,Liverfuntion tests ,renal function tests  )

Administer anti D TO THE Rhesus negative .

Admission to the ward for methotrexate administration.

Obtain informed written consent

Calculate woman s weight ,height,and body surface area.

The most widely used regimen for methotrexate is  single dose  given intramuscularly ,dose calculated  from the patients body surface area (50 mg/m square).14% of women with this regimen will reuire a second dose and 10% of them will require surgical intervention after consultation with consutant gynaecologist.

Follow up and monitoring of HCG levels on days 4 and 7.Hcg levels are expected to rise on day 4.

If HCG level fail to decrease  by 15% then consider giving a second dose.

HCG,Full blod count,LFT  ,U/E on day 7 to be done.

FBC HCG to be repeated on day 14 .

              

Weekly follow ups with Hcg levels till it falls to <5i.u/l

Abdominal pain is experienced by 75% of the patients.some pain is not an indication for ultrasound.TVS only indicated if rupture is suspected or pain is not relieved by simple analgeics.management should be guided by clinical findings as  pulse and blood pressure and peritoneal irritation.Discuss with consultant if surgical treatment is necessary.

Advice is given about  avoidance of intercourse  during treatment to avoid rupture,take plenty of water .avoidance of herbal remedies and vitamins with folate.

Advice about the use of effective contraception for 3 months after treatment .

Bereavement services are provided to psychological trauma to woman and her partner/

Send  a letter to woman s GP

Ensure clinical review is planned  to discuss issues regarding future fertility issues 

ectopic pregnancy answer Posted by MONA V.

 

Ectopic pregnancy medical management

 

a)      Discuss criteria for medical management  .

 

Medical  management of ectopic pregnancy is done only if the woman is hemodynamically stable  with minimal  or  no symptoms. She should be able to understand the need for regular follow up and have access to 24 hour emergency services.

B-hcg (human chorionic gonadotropin) levels should be less than 3000 iu/l  as higher levels have decreased  success rates of medical management. Hemoperitoneum on scan should be minimal ( less than 100 ) and not increasing for success.  Exact  size of ectopic is not clear  but large adnexal mass is associated with tubal rupture and not favourable for medical means. Available options at the local hospital , also need to be evaluated before offering medical ,management . The woman’s wishes preferences should also be taken into account especially regarding future pregnancy outcome.

 

 

b)      Describe how you will undertake medical management if criteria met.

 

The woman is counseled about the need for intramuscular (im.) methotrexate injections ,usually single dose which would kill the pregnancy in the tube and  avoid of surgery. She is counseled that pregnancy would not continue without serious health risks for her.

Full blood count ,LFT , urea electrolytes , group and save need to be done before methotrexate. She can stay overnight in hospital preferably or outpatient if ready access to hospital available. Methotrxate given  dose   of 50mg/m2 that is  75 – 90 mg im  on day 1 . B-hcg is measured on day 4  and day  7 and if it fails to fall  more than 15% then second dose of methotrxate is given . She is told about the side effects like stomatitis, conjunctivitis, gastrointestinal upset and photosensitive rash.  It is important that she avoid sexual intercourse after injection and maintain good hydration  .

 Contraception is needed for at least 3  months after injection  due to teratogenic effects of the drug..  75 % patients may get abdominal   pain after injection  due to tubal abortion which  usually settles with apin relief like paracetamol.   This pain  should be distinguished from  tubal rupture by monitoring pulse blood pressure.    15% (15out of 100)  may need a second dose of methotrexate.         7 in 100 patients  may  need surgical intervention due to tubal rupture as she must be told that.  

.  Clear written information to be provided to the woman and her carers  about symptoms like severe pain abdomen  giddiness which may warrant  laparoscopy  or laparotomy.

 

Anti  D prophylaxis as per guidelines is given 250 units im if she is Rh negative .

B-hcg is done weekly if falling until les than 20 iu/L.

Trans vaginal scan may be repeated  depending on b- hcg levels and her symptoms.She is told about  support groups like ectopic pregnancy .org.uk . She is given psychological  support and loss of pregnancy ,future fertility may be cause of distress.  Ectopic pregnancy is one off event future intrauterine pregnany chances are 60-70%  . Offer early scan in next pregnancy is advised as future ectopic overall  chances are 7 to 10  in 100 . Offer contraception for at least  3 months and then as per her need. 

Posted by shazard S.

A)

Regarding criteria for medical management, she must be haemodynamically stable with only minimal symptoms. Her first B hCG level must be <3000iu/l. The ectopic pregnancy mass must be <4cm with no cardiac activity. She must be able to attend and comply with follow up and access hospital services easily.

B)

Inform the consultant and nurse incharge of the early pregnancy assessment unit. Follow the unit protocol regarding medical management. Explain the diagnosis. Explain that medical treatment  is done as an outpatient and involves the use of methotrexate. Explain that it is a chemotherapy agent given as a single intramuscular dose. Explain that it stops growth of the trophoblast with subsequent reabsorbtion of the ectopic pregnancy mass. Explain that side-effects of methotrexate include stomatitis, conjunctivitis, gastrointestinal upset and photo-sensitivity skin reactions. Adverse effects include bone marrow suppression. Advise that she avoid sunlight, alcohol use and increase her fluid intake. Explain that methotrexate is teratogenic. Therefore avoid intercourse during follow up and use reliable contraception for at least 3 months. Explain that there is a 7% risk of tubal rupture and a 10 % risk of requiring sugery. Obtain written consent and document this discussion clearly in the patient's notes. Inform her that signs of tubal rupture include abdominal pain, shoulder tip pain and dizzyness. Advise her to return to hospital if these occur. Explain the abdominal pain occurs in upto 75% of patients having medical management and that admission may be required for assessment. Explain that differentiating between separaton pain and tubal rupture is difficult. Trans-vaginal scans and laparoscopy may be required. Offer written information detailing side-effects and complications of medical management. Offer hospital contact numbers. Assess the psychological impact of early pregnancy loss and offer couselling services if neccessary. If currently breastfeeding, advise her to desist while having methotrexate therapy.

Take blood for CBC, RFT, LFT and to be Grouped and saved. Use these values as baseline. Administer methotrexate as a single intramuscular dose of 50mg/m2 of body surface area. Serum BhCG levels are checked on days 4 and 7 after methotrexate given. The fall in BhCG levels should be >15%. A second dose of methotrexate is reuired if this does not occur. Serum BhCG is subsequently monitored once a week until the serum BhCG levels are <20iu/ml. Recognise that tubal rupture may occur at low levels. Perform a trans vaginal scan to measure the size of the ectopic pregnancy mass on day 7 then weekly . Deceasing size is reassuring. Offer surgery if rising or plateaued Bhcg levels, increasing size of the ectopic pregnancy mass or signs/symptoms of a haemoperitoneum.

ectopic pregnancy Posted by gouthaman S.

 

  1. She  should  be  hemodynamically  stable  with  minimal  symptoms  for  medical  management. Serum  hCG  level  should  be  less  than  3000iu/l.There   should  be  no  cardiac  activity  in  the  ectopic  mass.She  should  be  compliant  for  follow  up  and  should  return  easily  for  assessment  at  any  time  during  follow  up  to  the  hospital  services.
  2. She  is  explained  about  the  diagnosis  that  it  is  a  pregnancy  outside  the  uterus  which  cannot  survive  and  can  rupture  which  can  be  life  threatening.  She  is  managed  as   an outpatient.  She  is  managed  medically    with  Inj Methotrexate  intramuscular  single  dose  regimen which prevents ectopic pregnancy developing and aids resolution of the mass.  She  is  counselled  that  it  is  a  chemotherapeutic  agent. She  is  explained  that  significant  sideeffects  like  neutropenia  are  less  with  one  or  two  injections and other  side  effects  include  stomatitis,conjunctivitis,gastritis.Success  rate with  medical  management  is  nearly 90%  with  tubal  conservation  .Outcome  of  successful  pregnancy  is  usually  good.Only  15%  require  further  dose  of  inj  methotrexate.She  is  explained  that  majority  (75%)  experience  pain  abdomen  which  can  be  managed  usually  with  simple  analgesics.She  is explained  about  the  symptoms  of  rupture  including  pain abdomen,dizziness,shouldertip pain  and  advised  to  report  immediately  and  the  need  for  surgical  intervention.she  is  provided  with 24hrs  emergency contact  numbers of  EPAU unit.Sometimes  she  might  require  hospital  admission  if  doubt  exists between  separation pain  and tubal rupture.She  is  advised  for  regular  followup  for  hCG evaluation. Dose  of  methotrexate  is  calculated  as  per bodysurface area square metre.Usual  dose  is  50mg per squaremetre. It  is  given  after informed  consent.Baseline  investigations  include FBC, RFT,LFT,blood grouping. Follow  up  is  done  with  day4 and  day 7 serum HCG  values .IF  the  fall  beween day 4  and  7  is  more  than !5%  she  is  followed  with  weekly  serum hCG  until  level is  less  than  20iu/l and  weekly usg.If  fall  is  less  than  15%  she  requires  one  more  dose  of  inj methotrexate.She is advised  to  avoid  intercourse,maintain  good  hydration.Contraception  is  advised  for  3  months  since  methotrexate  is  terratogenic.Anti D  immunoglobulin 250u is  given  if unsensitised  Rh  negative.Surgical intervention is  needed  if  evidence  of  rupture,raising hCG levels.Psychological  support  is  given through  support groups.Information  leaflets are  provided.
Posted by FAUZIA  T.

(A)Criteria for medical managemnt of ectopic pregnancy are that the woman should be haemodynamically stable, have minimal symptoms, serum hCG>3000 IU/l, size of the ectopic should be>4cm and there should be no cardiac activity in the ectopic pregnancy.

(B)For the medical management of ectopic pregnancy, the diagnoses should be explained to the women. Her consent should be taken.I will tell her the outpatient procedure.She will recieve methotrexate injection single dose which is 50kg/m2body surface area, and also according to the unit protocol. During the treatment she needs to avoid sexual intercourse, have ample fluid intake and use contraception for 3 months as methotrexate is teratogenic. Before giving the methotrexate injection I will send for FBC,RFT,LFT and do grouping and save. I will tell her that I will measure serum hCG level  between days 4 and 7 and of the fall of the level of hCG is less than 15%. She might need another dose of methotrexate. TVS will be done after 1 week of recieving methotrexate to see the size of the ectopic. The side effects of medications are Conjunctivitis, Stomatitis and gastro-intestinal disturbances. I will also tell her that she can have abdominal pain which is separation pain and occurs in 75% of women, but since it is difficult to differentiate it from tubal rupture-incidence of which  is in 7% of women-so for that she will be admitted in the hospital for observation. If tubal rupture occurs  we have to take her for laparotomy. All these information will be documented in the notes. Writtten information will be given to her of treatment, follow up and  addresses local and national support groups.

Anti D will be given to her if she is non sensitized Rh-ve.

If the size of the ectopic is increasing or serum hCG level rises or if signs and symptoms of rupture then surgery needs to be done.

Ans essay 368 Posted by Liza S.

 

ANS----ESSAY 368
A)
Due to the risk of life-threating bleeding from an ectopic pregnancy, there are rigid criteria to be met before medical management becomes an option. Medical treatment for ectopic pregnancy Focused On Methotrexate use.
Criteria for receiving medical treatment can be divided into absolute indications and relative indications. Regarding absolute indication patient must be haemodyanamically stable with no active bleeding, and no haemoperitoneum.  It is a non-laparascopic diagnosis .Patient desire future fertility by conserving her tubes .General anaesthesia poses significant risk to her life .Patient is able to return for follow up care. Patient has no contraindication to methotrexate administration like liver disease, any kidney disease or lactating women. Relative indications are that the mass has to be an unruptured mass < 3.5 cm in size on scan. There is no fetal cardiac activity on scan. B-HCG serum level not exceed a predetermined value of 3000 ion/l 
B)
Methotrexate is the most popular agent used in clinical practice for ectopic pregnancy medical treatment. Overall success rate of medical treatment 89%.I will follow the unit protocol for ectopic pregnancy medical management. Clearly explain the diagnosis, benefit and risk to the women. This treatment can be used as outpatient basis and it involve the use of methotrexate which is a chemotherapy agent which targets rapidly dividing tissues such as trophoblastic and it will induce dissolution of trophoblastic tissues. Medical treatment can be used as Systemic methotrexate, transvaginal methotrexate, or locally via injection directly into the ectopic pregnancy. Systemic  methotrexate can be administered intravenously, intramuscularly . There are two commonly used methotrexate regimens: (1)Variable or multi dose methotrexate. Methotrexate 1mg/kg, intramuscularly given on alternate days (days 1,3,5,7),with folinic acid rescue on intervening days(days 2,4,6,8).A maximum of four doses are allowed.(2)Single-dose methotrexate, will  be calculated according to her body surface area(50 mg/m2 )intramuscularly.The effectiveness of the treatment is evaluated by the serial measurement of serum B-hCG levels which are checked day 4 and D7 after treatment initiated. A second dose may be given if the HCG do not fall by more than 15%over this time period, and is required in about 14 % of women. Single dose method appear to have higher persistent trophoblastic rate (8% vs. 4%), but single dose regimen is a more common protocol, propably because it requires fewer trips to hospital and facilitates compliance .Women must be made aware of the common side effects relate to the effect methotrexate has on mucosal surfaces and include conjunctivitis, stomatitis and gastrointestinal upset like nausea and vomiting, diarrhoea, abdominal pain, alopecia(rare).Tubal rupture can occur in 7% of women during follow up, the majority nearly 75 % experience some degree of abdominal pain which is attributed to tubal miscarriage .She must know that differentiating this “ separation pain” from pain due to tubal rupture is undoubtedly difficult and women should be admitted for observation and ultrasound  assessment if there is any possibility of tubal rupture .Surgical intervention may be required in less than 10%of women when there is increasing  hCG level, active bleeding or significant worsening of abdominal pain,or haemodynamic instability . Mointoring her treatment should be by serial full blood count ,liver and renal profiles preceding and following methotrexate administration.
Transvaginal intratubal methotrexate is another attractive option.It  can be done as outpatient  procedure  but has a significant failure rate 30%. Mifepristone  has been used in combination with methotrexate for the medical treatment of ectopic pregnancy but it is not practical as systemic treatment with methotrexate .Women should be advice to avoid sexual intercourse during treatment  and drink to thirst but to ensure that she did not become dehydrated .she should be provided contraception for at least 3 months  after methotrexate treatment as it can have the  estrogenic  effects .The duration of time to indictable hCGlevels was 35.5 days. It is important  for this patient to fully understand that she require an early ultrasound in subsequent pregnancies to exclude a recurrence of ectopic pregnancy and to seek a medical assessment early in pregnancy. Anti-D immunoglobulin will be given if she is rhesus negative.provide the 24 hour hospital connect number if she needed  in case of emergency,also provide her patient information leaflets.
 
ans Posted by Yingjian C.

a)

For medical management of ectopic pregnancy, patient should be asymptomatic with serum beta HCG of less than 3000iu/l, with no fetal heartbeat seen in the ectopic pregnancy on scan as well as no free fluid and ectopic pregnancy size should be less than 2.5cm. Patient must be able to be compliant to regular follow-up in hospital with regular bloodtaking. Patient must also have no contraindications to methotrexate such as renal or liver or pulmonary disease, not immunocompromised or breastfeeding. The hospital must have facilities for follow-up for medical management for ectopic pregnancy such as 24hour telephone hotline number and facilities for emergency operation. Patient must decide and agree for medical management.

b)

Patient must managed in a consultant led hospital unit with facilities for bloodtransfusion, emergency operations and ICU.  I will explain to her that she has a pregnancy outside her womb which has risks of rupture of the fallopian tube, bleeding and collapse thus must be treated. I will assess her contraindications for medical management. History regarding any abdominal pain or shoulder tip pain or increasing amount of bleeding  will be obtained, any other risk factors for ectopic pregnancy such as smoking, conception with artificial reproductive techniques, age and previous tubal/abdominal surgery or previous ectopic pregnancies. Patient’s current contraception and future fertility wishes must be asked. On examination, I would check her blood pressure, pulse rate and temperature, any pallor, any abdominal tenderness or guarding or masses, how large is the adnexal mass.  I would review any ultrasound scans done to check if any fetal heartbeat detected in the ectopic pregnancy, the size and any free fluid. I would check her serum BHCG and baseline investigations such as full blood count, renal panel and liver panel before giving her methotrexate. I would take consent from the patient after explaining  the procedure and follow-up for medical management of ectopic pregnancy: requires intramuscular injection plus serial blood tests.  I will explain risks of this procedure: she may experience increased abdominal pain after methotrexate, side effects of the drug such as gastrointestinal symptoms, mucositis, hypersensitivity. There is also 15% risk she may need additional interventional procedures and 7% risk of tubal pregnancy rupture with this mode of treatment. She will be given 24h hospital hotline number to call if she experiences increased abdominal pain, vaginal bleeding or feels unwell. She will be given written information regarding her ectopic pregnancy and current treatment as well as support and counselling. I will discuss alternatives: firstly, expectant management if she is asymptomatic with serum BHCG<1000 but has risks of tubal rupture and requiring medical or surgical intervention; the other alternative is laparoscopic salpingectomy or salpingostomy but has risks of anesthesia and surgery such as infection, blood transfusion.  I will stress the need for compliance to follow-up.  Intramuscular methotrexate will be given at 50mg/m2 of body surface area and a baseline serum BHCG taken (day 1), repeat serum BHCG will be taken on day 4 and 7. If there is a more than 15% decrease in BHCG between day 4-7, then she can be follow-up with serial BHCG. If there is a less  than 15% decrease in BHCG between day 4-7, then second dose of methotrexate must be given and serial BHCG monitoring. I will discuss with her regarding future contraception option; all are suitable. She has a 15% recurrence risk of ectopic pregnancy in the next pregnancy so she must book early to hospital once she knows she is pregnant.  I will check her blood group, if she is rhesus negative, anti-D Ig 250iu will be given to her postprocedure. The management must be documented and audited, local hospital protocols must be followed.

 

assay 368 Posted by huaida A.

A healthy 32 year old woman presents with a blood-stained vaginal discharge 7 weeks after her last menstrual period. She is found to have a left tubal ectopic pregnancy. (a) Discuss the criteria for medical management of ectopic pregnancy [5 marks]. (b) Describe how you will undertake medical management of ectopic pregnancy given that these criteria are met [15 marks].

A/

The woman should be asymptomatic and  hemodynamically stable. She should be able to compliance with the follow up protocol. The hospital should have a protocol for follow up and monitoring .the woman should be able to access the emergency unit at any time.Serum HCG level should be less than 3000IU/L.There should  be no cardiac activity in the ectopic mass.The woman should have no contRaindication to the usage of methotrexate such as peptic ulcer , renal impairment , liver impairment , or hypersensitivity to the drug.

She should counselled about the risks and complications including failure of the treatment and the need for active management including laprotomy.

B/

The woman should be invistigated before the start of the treatment ,CBC , RFT , LFT,and blood group are important.

There are options regarding routes of adminstration of the methotrexate, can be given intramusclarly, intravenously or directly in the ectopic mass(laproscopically or transvaginally under ultrasound guide.

It is unwise to give the woman the risks of laproscopic surgery with no definite treatment  to the ectopic if laproscope is used to inject the drug  so it is not used recently. Regarding direct injection in the mass, it is associated with increase risks of hematoma and abdominal pain.

Methotrexate should be given through the intramuscular rout.Either as single dose regiment or repeated dose regiment..

In single dose regiment ,methotrexate given in a dose of 50 mg/m2 ,the patient may develop an  abdominal pain between day 4-7 that may last for 4-12 hours.there would be arise in the HCG level between day 4-7. Also there would be minimal vaginal bleeding for few days howevere a brownish discharge may continue for 2-3 weeks. HCG should be measured on day 7  if there is less than 15% reduction in Serum HCG a further dose of methotrexate should given. then twice weekly HCG  level should be assessed and a weekly transvaginal ultrasound to assess the ectopic mass size,if it is droping HCG then can be measeared weekly until it is less than 20IU/L ,this may take up to one month  and in rare situation may last up to 3 months .

During this period of follow up the patient should avoid sexual intercourse.  Should use effective contraceptive up to 3 months after the methotrexate use because of the teratogenic effect of the drug.

NSAD should be avoided because of the interaction with the methotrexate, and if analgesia is needed paracetamol or Cocodamol would be good options. folic acid should be avoided as well as alcohol .The woman should report back immediatly any symptoms of severe abdominal pain,sever vaginal bleeding or syncopal attack .

No need to repeat the invistigations of CBC ,RFT, LFT after single dose regiment.It is cost effective.

In multiple dose regim,  methotrexate  is given in alternating  days , day 1,3 5,7  along with folinic acid in day 2,4,6 . The dose is 1mg/ kg.

Has same success rate as single dose regime, but with more side effects including GIT toxicity,conjectivitis , bone marrow supression . It need regular testing of CBC ,RFT , LFT.

The success rate of the medical treatment is a round 89%, with 14% risk  of need  for second dose of methotrexate,and 7% risk of tubal rupture.

Medical treatment   has a rate of intrauterine pregnancy and repeated ectopic pregnancy comperable to laproscopic treatment.

,

Posted by Lola B.

a) The patient must be asymptomatic. The initial bhCG levels must be <300U/ml. There has to be no fetal heart activity, the gestation sac must not be ruptured and there should be no blood in the POD. The patient must understand the nature of the treatment, and be compliant to follow up. She must be given a 24 hour contact number of the hospital, and the hospital must have services for emergency admission and treatment at all hours of the day. She must be given written information. 

 

b) I will explain to her the different options of managemnt -- surgical, medical and expectant, and tkae into account the patient's wishes. The chosen management must be medically sound. I will explain to her the meaning to ectopic pregnancy and what medical management entails, and the follow up plans. 

IM Methotrexate 50mg/m2 will be given in the gluteal region as a single dose. I will caution her about the size effects of stomatitis, conjunctivitis and GI upset. She can expect a transient increase in abdominal pain1 day after the injection. The bHCG levels will be repeated on Day 4-7 after the injection. I will expect the bHCG levels to fall by >15%. She should be advised to avoid sexual intercourse, maintain ample fluid intake and use contraception for the next 3 months. She must be adivsed to watch for increased PV bleeding or abdominal pain, for which she must return to the unit immediately.

If bHCG levels fail to drop optimally, she may need further assessment via TV ultrasound and possibly surgical intervention. If bHCG levles fall optimally, I will continue to monitor her levels weekly till the levels drop to below 20U/ml. If the patient is Rd D negative and unsensitised, 250IU of antiD Ig should be given within 72 hours. The patient must be explained and provided with written information abour the treatment received and what to expect. Treatment must be documented in the notes and she must be given an outpatient followup at D4-7 after the injection.

 

answer ectopic pregnancy qn Posted by Jyoti B.

For the treatment of ectopic pregnanacy by medical management the patient should be haemodynamically be stable with minimal symptoms,the  bhcg should be less than 3000iu/l, and an ultrasound showing an ectopic pregnancy,preferably with no cardiac activity.The patient should be explained the symptoms of rupture ectopic like severe abdominal pain, faiting attacks and should be asked report to the hospital immediatly.The hospital should be easily accesable to the patient and a 24hour contact number should be given to the patient in case of emergeny.Written information should be provided along with alternatives to the treatment .

(B)Once a medical management it decided,the patient can be managed on a outpatient basis.Her basline investigations like blood group,full blood count,blood urea, serum electrolyte, liver function test,baseline bhcg  should be sent.Injection methotrexate at a dose of 50mg/m2 should be givem as a single intramuscular dose.She should be explained regarding side effects like stomatitis conjuctivitis,nausea and vomitting.Patient should be sent home with instructions of having plenty of oral fluids,avoid alcohol, not to have intercouse or do any strenous activity and report immediatly to the hospital in case of severe pain abdomen,gidddiness or fainting attacks, Patient should be explained that about 75% patients may experience seperation pain which cannot be easily distinguished from pain of tubal rupture,hence she may require admission for assesment.Anti D should be given if patient is Rh negitive.Patient should be provided with written information regading sypmtoms of rupture ectopic, the risk of failure of treatment reqiring surgical intervention in about 7% of patients,repeate methotrexate reqirement.bhcg needs to measured on day 4 and day 7 afyer injection methorexate given, there should be a fall of atleast 15% between the two values,else a repeate dose of methotrexate of 50mg/m2 is given and cycle continued.There may be slight rise in values of bhcg from baseline and day 4,however they do not alter management.bhcg should be repeated every 1-2 weekly till it falls to about 20iu/l to look for resolution and rule out persistent trophoblastic disease,Transvaginal sonography could also be repeated at day 7 to look for decrease in size and resolution of the ectopic pregnancy.Reliable contraception to be maintained for atleased 3 months as methotrexate is teratogenic also pregnancy will intefere with bhcg follow up.

essay368 Posted by sujata B.

Please could you correct my essay. I mailed it on july  29th to make sure I,m early as I thought the correction was on first come first serve basis. I am comparing it with the correctd ones but please try so that I know how my answer is.,and look at the scope for improvement.

 

Posted by Farrukh G.

 

essay368 Posted by sujata B.
Thu Aug 2, 2012 08:53 am

Please could you correct my essay. I mailed it on july  29th to make sure I,m early as I thought the correction was on first come first serve basis. I am comparing it with the correctd ones but please try so that I know how my answer is.,and look at the scope for improvement.

 

Your answer has already been marked and posted under your name.

 

assay 368 Posted by huaida A.

please could you correct my assay . I mailed it on 1/8/2012. at 3:09 pm,  before some corrected assays.

 

Thanks

Essay 368. Ectopic pregnancy Posted by A H.

a) Criteria for medical management are that the patient should  have minimal symptoms and the beta HCG levl should be less than 3000 iu/L. On ultrasound fetal cardiac activity should not be present. She should be able to return to hospital easily for assessment during follow-up. The hospital should have a protocol for medical management of ectopic pregnancy.

 

b)The patient will be counselled about what to expect during treatment. She will be told that the complications include severe abdominal pain in up to 75% of patients, tubal rupture may occur in about 7% and about 15% will require more than one dose of medication. She will be told about the adverse reactions of methotrexate. She will be given  a 24 hour telephone contact  for advice should complications arise. She will be offered written information.

Methotrexate will be given by intramuscular injection . The dose will be calculated based on body surface area at 50 mg/metre squared.

Blood will be drawn on days 4 and 7 for repeat HCG determination. If the level drops by less than 15% between days 4 and 7 a second dose of methotrexate will be given.

 250 iu of Anti D immunoglobulin will be given if she is Rhesus negative.

She will be advised to maintain adequate fluid intake during treatment.

She will be advised to abstain from sexual intercourse during treatment. She will also be advised to use reliable contraception for three months after treatment because methotrexate is teratogenic.

ans to ectopic preg Posted by shraddha G.

 

A)     Criteria for medical management of ectopic pregnancy are as follows:

i)                    Patient able to comply with close follow up and have access to 24 hour emergency services

ii)                   No fetal heart in the ectopic mass

iii)                 Initial B HCG levels < 3000 IU/L

These patients are eligible for medical management, provided they should be able to follow up closely and are ready to use reliable contraception for 3 months post treatment.

 

B)      If these criteria are met, to offer medical management get her baseline FBC, RFT, LFT and serum electrolytes. These parameters are important to get done as they may alter after methotrexate. Calculate body surface area and then calculate the dose on basis of body surface area- 50mg/m2 body surface area by intramuscular route. Single dose is offered as this have 84-95% success rate, less side effects as compared to multiple dose regimen and does not require folinic acid supplementation. Get B HCG done on day 4 and day 7 and give another dose of methotrexate if levels of BHCG do not fall by more than 15 %.Provide complete written information about the need for close follow up , further treatment required and potential complications. Explain her that she may have abdominal pain following treatment which may occur in 60 % of patients and around 7 % patients may have tubal rupture during follow up. Ipsilateral tubal patency rates following medical treatment are 80 % and chances of subsequent intrauterine pregnancy are around 54% which is comparable to surgical management. Explain her chances of recurrent ectopic pregnancy are 8-10%.She should be advised that avoid sexual intercourse during treatment and use reliable contraception for 3 months after treatment because of possible teratogenic effects of methotrexate.

 

Ectopic oregnancy Posted by Shivamalar  V.
(a) The criteria for medical management include no fetal heart beat seen, serum beta hcg value should be less than 3000 iu/l, scan shows no free fluid or 15 % is expected. If not patient should be counseled for second dose methotrexate. If hcg level decline > 15 %, I will arrange for subsequent follow up twice weekly for beta hcg level and weekly for transvaginal scan to ensure the adnexal mass is reducing in size. I will advice the patient to attend to hospital immediately if she experiences increasing abdominal pain or per vaginal bleeding.I will ensure patient has direct contract to the emergency department or EPAU. i will advice patient to drink plenty of water and avoid pregnancy in next 3 months as methotexate is teratogenic. I will counsel patient to use an effective contraception carefully avoiding intrauterine contraceptive device. I will follow up this patient until her beta hcg value is less than 20 iu/l. Following this I will reassure patient regarding future pregnancy. I will explain risk of tubal pregnancy in future is similar to surgical treatment and 54% chance of successful intrauterine pregnancy in subsequent pregnancy.
Re typing answer for EP(missing a paragraph)-Shivamalar Posted by Shivamalar  V.
(a)The criteria for medical management includes no fetal heart beat seen, serum beta hcg is less tha. 3000iu, scan shows no free fluid or free fluid less than 100mls in pouch of Douglas the size of adnexal mass is less than 4 cm. And patient should be compliant to follow up following treatment. (b) this patient need counseling before starting treatment. The choice of medical treatment will be methotrexate. The dosage will be 50mg/m2. The success rate is up to 85% with single dose treatment and 15 % of patient may need repeat dose treatment during follow up. 7 % of patient may experienced tubal rupture during treatment necessitating surgical treatment. 79% patient may experience abdominal pain during the initial 4 days after treatment. The dose is calculated based on body surface area. She need to know the side effects as well which is stomatitis, conjunctivitis, pneumonitis and abdominal pain. I will provide written information and obtain informed consent from her. I will measure her weight and height to calculate the dose. I will check on her baseline fbc, renal function - urea electrolytes and creatinine level as well as liver function test as methotrexate is contraindicated in patient with renal/liver failure.I will administer the injection intramuscularly and arrange for follow up with repeat beta hcg on day 4 and 7. A decrease in beta hcg of > 15 % is expected and if not I will counsel this patient for second dose methotrexate.if the initial, fall is more than 15% I will arrange for weekly beta hcg level check until then drop is < 20iu. I will provide details of emergency contact number or 24 hr access to hospital before discharging this patient. I will advice her to contact hospital immediately if she experiences severe abdominal pain or per vaginal bleeding. During the course of treatment I will advice this patient to drink plenty of water and use effective contraception and avoid pregnancy for next 3 months. This is because methotrexate is teratogenic. I will council patient regarding future pregnancy and 54% patient will have successful intrauterine pregnancy and chances of recurrent ectopic in future is similar to surgical treatment.