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MRCOG PART 2 SBAs and EMQs

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Essay 293 - Ectopic pregnancy

Posted by namreen M.

a) This type of presentation can be seen with;

1. Ectopic pregnancy

2. Miscarriage

3. Molar pregnancy

4. Bleeding  from other causes like cervical polyps or carcinoma and abdominal pain of non gynecological origin.

The patient should be assessed by taking a brief history of her symptoms;

onset ,duration and nature of pain whether colicky or continuous,presence of shoulder tip pain,any syncopal attacks which indicate an ectopic pregnancy.

previous history of PID, surgical treatment for tubal disease or ectopic in the past

history of contraception

Pulse rate,BP and temperature should be recorded . Examine her abdomen for any distension,guarding,rigidity or rebound tenderness.A p/s examination to look for any cervical dilatation and presence of fetal tissue at the os should be carried out.A p/v examination for uterine size,cervical excitation,adnexal mass or tenderness should be carried out.

If the patient is haemodynamically stable i will go for a b hcg titre and a TVS.

If the patient is in shock ,a prompt surgical management is required.

b) Non surgical treatment for ectopic includes;

expectant management and medical management both of which involve no anaesthetic and surgical complications and morbidity associated with the surgical interventions in addition to the cost benefits and hospital stay.

Expectant management should be offered to patients who are hemodynamically stable, asymptomatic, b hcg below 1000iu/ml, adnexal mass <3cm in dia with no FHS on USG,peritoneal fluid <100ml and who are compliant with the follow up and have easy access to 24 hour hospital emergency facilities.These patients can be followed up  after 48-72hrs with twice weekly b hcg and weekly TVS to ensure reduction in size of the adnexal mass and b hcg titres followed by weekly b hcg till 20iu/ml.Active intervention is needed in case of rising or plateuing hcg levels or if patients develop any symptoms.

Medical management involves administration of i/m methotrexate single or multiple doses(50mg/m2) depending on the progress.It should be offered to patients with hemodynamic stability, hcg <1500iu/ml, adnexal mass <3.5cm in dia with no FHS on USG,and those who are compliant with follow up and have easy access to hospital.75% patients have pain after the dose  and 7% have a rupture.A success rate of 85% has been reported with ipsilateral tubal patency of 80%.They have to be followed up with serial b hcg on day 4 and 7.A decrease of <15% btween day 4 and 7 is an indication for the second dose.

A written information should be provided to all such patient and need for emergency intervention should be explained.

ectopic pregnancy essay 923 Posted by celine  S.

This scenario demonstrates that this could be an emergency of a ruptured ectopic pregnancy,thretened miscarriage untill otherwise proved.Quick history suggestive of ectopic pregnancy i.e.previous ectopic,miscarriage,progestrone only contraception,h/o PID in the past,assesment of the vitals pulse,bloodpressure,respiratory rate,pallor oxygen saturation is vital to initiate appropriate action.Abdominal examination to look for rebound tenderness(in ruptured ectopic ),speculum examination to note opened cervical os,products of conception at the os gives a dagnosis of inevitable miscarriage.Otherwise a closed cervix,with minmal bleeding (threatened miscarriage),cervicalexcitation pain,if fornices are full and tender alerts the clinician  towards action ,in view of ruptured ectopic pregnancy.urgent call for help,and establishing ABC are primary and lifesaving in every bleeding women.Quickly send blood for bloodgroup and crossmatching (if transfusion is indicated)or group and save if the women is stable .Other investigations to be sent are baseline betahcg and FBC,(if women is in shock renal funtion tests,LFT,caogulation screen ).A Transvaginal USG(TVS) will clinche the diagnosis of an ectopic,amount of peritonial collection,or a miscarriage.

The nonsurgical management are expectant management ,and madical management.

Expectant management is dealt with if the women is stable and the values of beta Hcg does not exceed more than 1000 i.u./l,the TVS shows a sac size of 3-4 cms.with lessthan 100 ml of blood in the Pouch of douglas.This seems  eonomical as it involves outpatient management,but may be expensive in the long follow up period,as the women is followed up twice a week ,with beta HCG values to look for decling values from the baseline,and an USG to know the reduction in size of the sac.There can be a requirement of medical management or a surgical emergency is some cases.Antid 50 ug/100.u is given to nonsensitized women who are RH negative.

Medical management is with a single dose of 50mg/msq of body surface,most women may require 75mg-90 mg.of antifolate drug methotrexate,75% of women respond to this treatment,14% may require a repeat dose. Beta hcg should fall less than 15% of the baseline value ,between day 4 -7.10% of women may require surgical management.Women most suitable are those with beta hcg below 3000 i.u./l,with usg sac size of lessthan 5 cms,withoutcardiac activity,and a minimal peritonial collection the women should be asymtomatic or with less symptoms.This regime is economical as treatment is given as outpatient and indirectly also saves time and costs less to the carers and the patients as well.Methotrexate may give rise to a sorethroat ,GIT upset,somatitis,conjuctivitis,as well as a slight rise in the betahcg values.In 15% of women it is sometimes difficult to differentiate between a tubal rupture and a seperation pain which may cause anxiety to the women as well as the clinician.Hence compliance is important ,and therefore a patient information leaftlet is provided.It is also important to educate the women regarding possible teratogenic risk if she gets pregnant .Hence reliable contraception should be provided for atleast 3 months,actually she should abstain from sexual activity as it may trigger tubal rupture untill followup is complete.Surgical treatment may be required as an emergency.

 

 

ectopic pregnancy Posted by saurav prakash M.

    a) these type of presentation is more commonly can be with threatened miscarriage,ectopic pregnancy,molar pregnancy,cervical or endometrial polyp,pregnancy with other systemic disease involving abdomen eg inflammatory bowel disease.a thoroghu and prompt relevent history along with clinical examination should be performed in haste.h/o chronic antecedent pain lower abd(pid and ibd),h/o previous tubal surgery(recurrent ectopic),nature and type of pain including excruciating shoulder tip pain(ectopic),h/o passage of vesicle like material may be found in molar pregnancy.in examination severity of pallor,pulse,bp and urine output must be assessed to look wheather she is in shock or not.p/s examination to look for open os or active bleeding,tvs to ascertain her fetal viability,position,membrane status should be looked instantaneously.if there is suspicion for ectopic then serum b hcg shouldbe assessed.if general hemodynamic is not stable then she should be taken to the ot immediately.                                                                                                                                                                       b)    nonsurgical method for treatment of ectopic is only instituted if the patient is hemodynamically stable,serum b hcg is <3000iu/lwith minimal symptoms and signs.a proper informed consent (preferably written) should be taken.patient has to be compliant enough to understand the needs of multiple f/u,chances of more interventions(either surical or medical),possibilities of persistence of trophoblastic disease following initial treatment,possible side effect of therapy etc.most commonly used medical management is single i/m inj of methotrexate(50mg/m2).serum b hcg should be followed up on day 4 and day 7 of therapy.decline of <15% between these two reading requires a second dose.the presence of fetal cardiac activity is associated with high failure of medical therapy.outpatient treatment saves the costs and anxiety with medical therapy in compliant and willing patient.local protocols may be accepted in institution of primary therapy and follow ups.   

ectopic pregnancy Posted by saurav prakash M.

 a) these type of presentation is more commonly can be with threatened miscarriage,ectopic pregnancy,molar pregnancy,cervical or endometrial polyp,pregnancy with other systemic disease involving abdomen eg inflammatory bowel disease.a thoroghu and prompt relevent history along with clinical examination should be performed in haste.h/o chronic antecedent pain lower abd(pid and ibd),h/o previous tubal surgery(recurrent ectopic),nature and type of pain including excruciating shoulder tip pain(ectopic),h/o passage of vesicle like material may be found in molar pregnancy.in examination severity of pallor,pulse,bp and urine output must be assessed to look wheather she is in shock or not.p/s examination to look for open os or active bleeding,tvs to ascertain her fetal viability,position,membrane status should be looked instantaneously.if there is suspicion for ectopic then serum b hcg shouldbe assessed.if general hemodynamic is not stable then she should be taken to the ot immediately.                                                                                                                                                                       b)    nonsurgical method for treatment of ectopic is only instituted if the patient is hemodynamically stable,serum b hcg is <3000iu/lwith minimal symptoms and signs.a proper informed consent (preferably written) should be taken.patient has to be compliant enough to understand the needs of multiple f/u,chances of more interventions(either surical or medical),possibilities of persistence of trophoblastic disease following initial treatment,possible side effect of therapy etc.most commonly used medical management is single i/m inj of methotrexate(50mg/m2).serum b hcg should be followed up on day 4 and day 7 of therapy.decline of <15% between these two reading requires a second dose.the presence of fetal cardiac activity is associated with high failure of medical therapy.outpatient treatment saves the costs and anxiety with medical therapy in compliant and willing patient.local protocols may be accepted in institution of primary therapy and follow ups.                                                                                                               expectant management can be for willing patients having hemodynamic stability,usg proven tubal ectopic pregnancy without cardiac activity,initial serum b hcg <1000iu/l.their serum b hcg should be followed up wkly until it becomes<20iu/l.preferably the b hcg should be decreased by 50% at the end of first wk and the tvs should show no tuboovarian mass by the end of 7 th day.councelling regarding f/u and good compliance are also important here.

Ectopic pregnancy Posted by RIZ Posted by Attia R.

A}

As the patient came with h/o pain in LIF and vaginal bleeding with poitive pregnancy test our  top differential diagnosis will be miscarriage{ threatened / incomplete }or ectopic pregnancy .A detail history about the amount of bleeding and history of passage of clots or tissue should be taken as could be threatened /incomplete miscarriage.. I will ask  about menstrual history, including LMP,regularity and legth of cycle,and associated dysmenorrheal. I will ask about risk factors for etopic,like history of previous ectopic ,pelvic infection,use of intrauterine device ,any previous tubal surgery and hormonal contraception specially progesterone only pills.

Patient vital signs ,pulse ,blood pressure,should be checked .i will examine the abdomen for uterine size, tenderness ,rebound tenderness,rigidity to look for  signs of perotinitis if any.vaginal examination for amount of bleeding .vaginal examination to look for cervical os opened/CLOSED,any tissue  in cervical os if opened,and ,cervical motion tenderness . I will look adnaxal tenderness and mass during vaginal examination.

I will also secure intravenous access and +-IV fluid,blood for group and save, and serum beta HCG levels in case ectopic.and I will arrange a TV ultrasound to localize pregnancy.

B}In nonsurgical management we have  two options ,.Expectant management and medical.

Patient can be managed expectantly {wait and watch}I f following criteria meets .i.e

Beta hcg is less than 1000 i.u,no or minimum fluid in pelvis .mass in adenaxa less than 35 mm .patient is compliant and able to come back in case feels pain and patient acceptance of the management.if all these criteria is met ,patient can be advised to repeat  beta hcg after 48 hours,.DOUBLING BETA HCG OR RISE MORE THAN 60% signifies normal intrauterine pregnancy and in that case the TV ultrasound should be repeated.If falling beta levels more than half of previous  failing pregnancy and patient can repeat weekly beta hcg until falls below 20 i.u.Patient must be advised to report to hospital in case feels pain. This mode of management offers no intervention and may be acceptable for patient who donot want any medical interventions.This method preserves tubes and higher chances for future normal pregnancy ...Exp.management  donot require hospital admission and is cost effective. No anti D required in case patient RH negative. .On the other hand it requires a patient who is reliable and is ready to follow up{patient acceptance.}.There is risk of tubal pregnancy rupture and bleeding requiring emergency surgery..Follow up may be prolonged ,and risk that she may not resolve pregnancy and may need further medical or surgical intervention.There is risk of recurrent ectopic same tube in future if in case unhealthy tube.

Second option is medical management .Injection methotrexate is used in single or multiple regimen to stop the growth of ectopic mass if the following criteria meets.

Beta hcg less than or =1500iu,size of ectopic mass not more than 35 mm,, no fetal heart beat ,no or minimum fluid in pelvis ,no contraindication to drug and patient acceptance.Patient needs to repeat beta hcg on day 4 and day 7 .if harmone is falling can be weekly followed up in early pregnancy clinic until beta hcg below 20 iu.

Response  rate 90% with methotrexate.

Method offers tube preservation increasing chances of spontaneous pregnancy donot require hospital admission.Donot require anti  D prophylaxis in case mother Rh negative.

while 10-15% may not response and may require second dose ?surgery . Abdominal pain 60-70%common after injection mimicking rupture so patient need detail counseling .risk of tubal rupture intra bdominal bleeding ,emergency laprotomy.Beta hcg level rise on day 4 ,may increase anxiety for patient.side effects of drug stomatitis ,photo sensitivity ,and liver function abnormalities.May not be acceptable for patient.It is teratogenic drug and patient needs to wait at least 3 months to conceive again.multiple injection may be required  .As methotrexate is cytotoxic drug ,an informed consent with full verbal counseling is necessary.

 

 

Posted by Kelly H.

 

a)

Any woman with a positive pregnancy test and abdominal pain or bleeding could be an ectopic pregnancy until proven otherwise and ruptured ectopics continue to be a significant cause of maternal mortality in the UK. Therefore my assessment of her should be timely and aim to determine the cause and ultimate time frame and method of further management. The main differential diagnoses in this scenario are: ectopic pregnancy, miscarriage, cervical polyp, cervical ectropion, and infection.

I would take a history eliciting the onset of pain, nature of pain, site of pain, extent and onset of bleeding or any precipitating events like sexual intercourse. Does she have any risk factors of ectopic pregnancy? (for example previous ectopic pregnancy, did she conceive with IUCD or on the contraceptive pill, is she a smoker, does she have a history of PID / STDs, has she had previous surgery). What is her obstetric history including cycle length and parity, has she had any cervical smears to date and I would establish what her attitudes towards this pregnancy are.

I would examine her. If she is unstable or bleeding heavily I would assess her in an ABC stepwise manner. Her basic observations should be taken, especially heart rate. I would examine her abdomen and elicit any tenderness, guarding or rebound tenderness. I would perform a speculum examination with consent and assess the cervix; is the cervical os open, is there bleeding from the os, is there a polyp or ectropion, how much bleeding is there? I would also take high vaginal swab and endocervical swab. I would then perform a vaginal examination, particularly assessing for adnexal tenderness or cervical excitation, occasional you may be able to palpate an adnexal mass.

I would gain IV access and would take bloods for FBC, G+S (XM if there was clinical evidence of haemodynamic instability or heavy blood loss either vaginally or intrabdominally) Beta HCG and Progesterone. In a viable intrauterine pregnancy I would expect a 66% rise in HCG in 48 hours, a plateauing or suboptimal rise would be consistent with an ectopic pregnancy and a significant drop would be indicative of a miscarriage I would arrange a transvaginal ultrasound to assess location and viability of pregnancy. This would be interperated in conjunction with clinical picture and HCG levels. Progesterone is useful in improving the accuracy of diagnosis (less than 20 is likely a failing pregnancy irrespective of site, 20-60 is increased risk of ectopic if HCG >25 and if Progesterone >60 it is likely a progressing pregnancy, usually intrauterine)

Depending on the findings and results of the investigations would depend on my further management.

 

b)

The treatment options for ectopic pregnancy are: conservative, medical or surgical

80-92% of appropriately selected patients with ectopic pregnancies will respond to medical treatment with Methotrexate, thus avoiding the need for surgery. Although it is estimated that 80% of ectopic pregnancies would be suitable for medical management, in practice, less than 50% are managed in this way, with the remainder undergoing surgical salpingectomy, or less commonly salpingostomy.

The benefits to medical management, are of cost effectiveness and the avoidance of surgery and its associated risks and the preservation of the affected fallopian tube.The risks of surgery are bleeding, infection, removal of tube, removal of ovary, incomplete removal of ectopic pregnancy and risks of general anaesthetic. There is an 8% risk of remaining trophoblastic tissue with salpingostomy  and 20% may require further treatment.These failure rates are less with salpingectomy with similar future pregnancy rates.  If we compare this to MTX treatment, there is 8-20% failure rate.There are no increased rate of subsequent pregnancy despite preservation of the affected tube with medical treatment. 70-80% will expereince abdominal pain and women cannot conceive within 6 months of treatment.

The indications of medical management are: HCG < 5000 ( although often a cut off is 1500), no FHR, haemodynamically stable, gestational sac < 3.5cm, empty uterus, no medical contraindications, willingness to accept blood products, good compliance and patients wishes. If these criteria are met 80-92% would be successfully treated with Methotrexate. 

Other indications where MTX would be suitable would be in difficult and high risk ectopic sites like scar ectopics or cornual and interstitial ectopics ( the level of HCG can be over 5000 in this situation). These are typically very difficult to manage surgically and may result in massive blood loss and hysterectomy. Therefore the use of MTX may be safer.

Situations where MTX is not suitable and therefore should not be used are: unstable, FHR on USS, gestational sac > 3.5cm, IUP has not been excluded, HCG > 5000, anticipated non-compliance or the patient wishes to conceive within 6 months.

Patients should be closely monitored during MTX treatment and assessed for any signs of failing treating (eg significant increase in pain, rising HCG on day 7 or less than 15% fall) and decision as to whether surgical intervention required at this point.

essay 293 Posted by geeta M.

a)First I will assess her hemodynamic status by checking her pulse rate,B.P,respiratory rate to check whether she needs any immediate resuscitative measures.By her history it may be a pregnancy related complication such as miscarriage,ectopic  or a molar pregnancy.I will ask her if she is having shoulder tip pain or fainting attacks as this maybe suggest an intraperitoneal bleeding.I will assess the amount of bleeding and whether she is passing clots or any product of gestation.I will do a per abdomen examination to detect signs of acute abdomen like guarding or rigidity that will determine the type of urgency of her management.I will do a per speculum examination to check the cervical status and whether the os is open suggesting miscarriage.I will do a per vaginum examination to check uterine size,tenderness,adnexal mass,cervical motion tenderness to rule out ectopic.I will do an ultrasound scan  to get an accurate diagnosis whether its intrauterine pregnancy or ectopic or  miscarriage and if ectopic its size and presence of free fluid in pouch of Douglas.Also I will secure an intravenous access and send blood sample for full blood count,group and save and clotting screen.

b)After confirmation of ectopic pregnancy,non surgical management will only be suitable if she is hemodynamically stable and meets certain criteria for expectant or medical management.Expectant management can be offered to her if on ultrasound there is no  heart activity in  ectopic mass,there is less than 100 ml of fluid in POD,HCG is less than 1000 iu/l.But rupture may still occur and so she will be provided with clear written information to be compliant with follow up and she should have easy access to hospital.

Medical management by methotrexate is another option.The criteria are there should be no fetal heart activity,HCG level should be less than 3000 iu/l.With single dose methotrexate of 50 mg/m^2,there is success rate of around 90%.This is less expensive ,requires less intensive monitoring and has less side effects as compared to multiple doses.But she should be informed that there is a chance of increased abdominal pain following treatment.Since there can be a transient increase in HCG level between day 1 and 4,it should be measured on days 4 and 7.Sh e may need further dose of methotrexate is HCG level falls by less than 15% between days 4 and 7.

She should have easy access to hospital as 7% of women experience tubal rupture during follow up.She should be provided with written information about need for further treatment and complications that may arise such as alopecia,stomatitis,pneumonitis,multiple ovarian cysts and failure of therapy.Due to possible teratogenic effects,she should use reliable contraception for 3 months after treatment.Intrauterine pregnancy rate after methotrexate treatment is around 55%,but there is around 10% recurrence rate of ectopic as compared to those following laproscopic salpingostomy.

Non surgical management reduces cost of stay in hospital,surgical cost and surgical morbidities and enables tube preservation.

Essay 293- ectopic pregnancy. Posted by John S.
(A) Initial assessment would evaluate the patients airway, breathing and circulation. An assessment of her haemodynamic status and observations including blood pressure, pulse, respiratory rate and temperature are essential. Ideally an early warning score should be calculated. A full and comprehensive history should be taken. The presenting complaint should be discussed and an estimation of the volume of bleeding, the passage of any products of conception. This will help assess severity and the possibility of complete or incomplete miscarriage. The timing, type and duration of pain should be discussed as this may give clues to the cause of pain. Acute onset may suggest ectopic rupture, cramping, intermittent pains may suggest inevitable miscarriage and any history of pelvic pain predations the pregnancy may suggest other gynaecological or surgical causes; cyst accidents, torsion. A full surgical history may also reveal previous operations. The presence of urinary or bowel symptoms may suggest constipation or UTI as a cause. Any risk factors for ectopic pregnancy should be identified. This includes history of chlamydial infection or PID, endometriosis, any fertility issues including IVF, previous history of ectopic or history of tubal surgery. A full examination should be performed. systemic examination may identify haemodynamic compromise or rash suggesting infection. Abdominal examination will identify an acute abdomen if evidence of peritonitis or guarding is found. A speculum examination may find products of conception at the cervical so which can be removed to settle the bleeding and a bimanual examination will identify any adenexal masses, adenexal tenderness or cervical excitation. This will help decide the urgency in which investigation and management needs to be instigated. This assessment needs to be done in a sensitive and careful manner. This is a distressing time for most women and can have important psychological sequalae. (B) Non surgical management offers avoidance of the complications of surgical management such as visceral organ injury, anaesthetic risk and, depending on the individual case, may offer a safe, cost effective way of managing women as an outpatient which has numerous psychological advantages. Arguably, however, non surgical management of suspected ectopic requires longer follow up and longer resolution of the pregnancy, is not always successful avoiding surgery and often means that a longer time is required to secure the diagnosis and offer initial treatment. Furthermore, non surgical management is not suitable for everyone and laparotomy will remain the most expedious method of managing the unstable patient. Laparoscopy too, offers a fast diagnosis and management which is often preferred by women, who are managed quicker, with less resources spent on follow up. Training in laparoscopy is difficult, so why abandon such an effective and often acceptable tool in a women's management. Non surgical management may either be medical or expectant. Expectant management is specifically for women with an initial bhcg level less than 1000, a symptomatic with no free fluid in the pelvis. She should not have a live ectopic and often this treatment is reserved for 'pregnancy of unknown location". This too, may allow a pregnancy to resolve spontaneously but require much longer follow up. This may prove a drain on laboratory and sonography resources as well as the early pregnancy clinic. Expectant management may not avoid further medical or surgical intervention but may be a suitable alternative for women unsuitable for medical management with methotrexate because of their medical history and wishing to avoid surgery. Medical management with methotrexate 50mg/m2 offers faster solution than expectant management. Again, diagnosis can be delayed as diagnosis is often dependent on serial bhcg,scan findings and the overall clinical picture. Not all patients will be suitable for methotrexate management as liver and renal function need to be normal and any history of liver disease or clotting disorder may make medical management unsafe. Patients also need to have a bhcg less than 3000, no fetal heart detected within the ectopic and no free fluid. Non surgical management also allows potential preservation of the Fallopian tubes. This is often greatly desired in women, who often have predisposing factors for ectopic such as infertility, endometrioisis or past chlamydial infection. However, it could be argued that assessment of the tubes by diagnostic lap and removal of the affected tube reduces the risk of recurrent ectopic. Methotrexate itself has significant side effects such as diarrhoea, vomiting and lethargy and affects the timing of a future pregnancy. The cost effectiveness given the additional outpatient management, laboratory testing is contentious versus potentially one night in hospital with minimal follow up given that not all cases of medical management will be successful, having to resort to surgical management in the end.
Posted by Angeldust S.

 

(a)This woman has ectopic pregnancy until proven otherwise. On arrival, her vital signs such as heart rate, blood pressure and oxygen saturation levels are taken as she can be potentially haemodynamically unstable and may require initial resuscitation. Once she is stabilized, a history is taken for last menstrual period, symptoms of abdominal pain or per vaginal bleeding. Any previous pregnancies including terminations of pregnancy and previous ectopic pregnancies is asked. Risk factors for ectopic pregnancy including number of sexual partners, previous pelvic inflammatory disease, previous pelvis surgery, IUCD or progesterone-only pill use, or smoking are elicited to assess her risk for ectopic pregnancy. A physical examination includes general inspection for pallor signifying anemia, abdominal palpation for rebound tenderness or guarding, which may signifiy haemoperitoneum.  A speculum is carried out for per vaginal bleeding and products of conception to exclude miscarriage.  A vaginal examination to elicit cervical motion tenderness which may signify haemoperitoneum.

Investigations include a transvaginal ultrasound scan to exclude intra-uterine pregnancy.  If an empty uterus is seen, any adnexal masses need to be noted as the chance of ectopic pregnancy is high.  If an adnexal mass is seen, the size is measured, any cardiac activity is noted to decide on expectant, medical or surgical management. Free fluid in pelvis is suggestive of a ruptured ectopic pregnancy. Haematological investigations for FBC, group and cross match in preparation for surgery and to assess for anaemia. B-HCG is despatched for level trending.

(b) Non surgical management includes expectant management and methotrexate. Non surgical management allows tubal conservation but can only be offered if the patient is haemodynamically stable. Expectant management requires the woman to have an ectopic pregnancy with dropping b-hcg and minimal pelvic free fluid < 10ms on ultrasound. Pros include low cost and avoidance of surgery and risks including anaesthetic risks, visceral injuries and tubal loss. However, the patient needs to have repeated transvaginal ultrasound scans and regular bhcg levels taken till its resolution which may take 3-4 weeks or even longer. The patient may require surgery anytime if any evidence of bleeding or haemodynamic instability occurs which is unpredictable, inconvenient and potentially life threatening. There is a small risk of persistent trophoblastic disease which may require methotrexate eventually.

Methotrexate therapy can be considered if the ectopic pregnancy is less than 3cm, has no cardiac activity, bhcg between 1500-5000 and minimal free fluid in the pelvis. It has high success rate of 80% and a subsequent pregnancy rate comparable to surgery. It is also cheaper and avoids surgical risks. Treatment can be given outpatient hence no need for hospital admission. However, methotrexate has side effects including stomatitis, neutropenia, alopecia, nausea and vomiting. The patient may find in unacceptable that she cannot get pregnancy for the next 3 months as methotrexate is teratogenic. This treatment is not suitable for women who is not keen for regular follow-up and is non-compliant as side effects and bhcg levels cannot be monitored to assess success of treatment. Surgical management may eventually be required if methotrexate fails i.e bhcg increasing or plateu-ing, evidence of rupture on ultrasound. Severe abdominal pain due to methotrexate may occur in 70-80% which can be uncomfortable and may require subsequent admission. 

Non-surgical management requires careful patient counselling and ensuring patient's understand of risks and benefits and written information needs to be given. THe final decision and subsequent management plan needs to be documented clearly in the patient's notes. 

Ectopic pregnancy Shabana H Posted by Shabana H.

The cause may be pregnancy related like ectopic pregnancy,threatened miscarriage, molar pregancy or local cause like cervical polyp ,cancer cervix .She is enquired about nature of pain ,aggravating and relieving factor,any syncopal attack or shoulder tip pain to rule out ectopic pregnancy.Any history of passage of blood clots or fleshy mass points to incomplete abortion.If there is history of PID , ART more likelihood of ectopic pregnanacy.Her vitals are checked ,abdominal examination for tenderness,guarding,rebound tenderness for signs of ruptured ectopic pregnancy.Speculum examination for checking bleeding ,status of cervix ,any POC .Bimanual examination for uterine size ,tenderness fornicial tenderness cervical excitation  seen.

B)Non surgical managemant constitutes expectant management and medical mamnagement.

When woman is hemodynamically stable,size of adenaxal mass <3 cm,serum beta hCG<1000 IU/ml,fluid in pouch of Doughlus <100ml ,facility for TVS and beta hCG monitoring she can be maanged expectantly.Medical m/m consist of either single or multiple doses of injection Methotrexate in dose of 50 mg/sq.mt body surface area.For medical m/m size  should be <3.5 cm ,beta hCG <3000IU /ml.These m/m  can be done on out patient basis but requires patient compliance for regular visit for TVS assessment and beta hCG monitoring They are not associated wih complications of anaesthesia.But the number of visits to hospital are increased.There might be chance of failure of these m/m interms that rupture of ectopic pregnancy may occur and need of emergency laparotomy may arise.In medical m/m side effects of methotrexate  may occcur like stomatitis ,photosensitivity ,GIT upset.There may be separation pain after first dose of injection methotrexate which can confuse with rupture of ectopic pregnancy.Medical treat is as effective as laparoscopic salpingotomy.Systemic multiple doses  doses are effective when beta hCG <3000IU/ml and single dose when beta hCG<1000 IU/ml.There fore patient selection should be appropriate.

Non-surgical ttt of EP Posted by Karmin J.

A.

Past gynaecological history include prior ectopic and/or miscarriage whether it is induced or spontaneous. Sexual history should be enquired including multiple sexual partners or new one in the last six months for PID that may cause ectopic. Social history like smoking that may cause ectopic. Contraceptive also to be asked as minipills and CuT 380 may associated with ectopic. Ovulation induction and IVF should be enquired as EP can occur with. Past surgical history including pelvic surgery should be asked.

B

Nonsurgical treatment including expectant and medical treatment can be adopted. The patient should be compliant and amenable for call at any time and follow-up. The hospital should have expertise in Laparoscopy and emergency laparotomy around the Clock. In addition to that, the ectopic patient must have fulfilled criteria for non-surgical treatment. The ultrasound finding should reveal gestation sac less than 3.5 cm, no fetal cardiac activity, and minimal fluid in Pouch of Douglas less than 200ml. Also, the patient should be haemodynamically stable and asymptomatic or with mild pain. Initial beta hCG, CBC and liver function test should be done. If beta hCG less than 1000 IU/ml expectant management can be offered with serial  follow up initially twice weekly then weekly till beta hCG become less than 20 IU/ml. the success rate is 70 %. If the Beta hCG less than 3000 IU/ml (recently recommended level 1500 IU/ml). medical treatment with methotrexate can offered either single or multidose regimen with dose 50 mg per square metre body surface area for the first and 1 mg/Kg body weight for 4 doses alternating with folinic acid for the later. For single dose regimen Beta hCG should assessed on Day 4 after injection and the Day 7. If decreased more than 15 % serial assessment initial biweekly then weekly till become less than 20 iu/ml. If decrement less than 15 % second dose should be given with serial assessment of beta hCG. Patient should instructed to avoid sexual intercourse, non- steroidal anti-inflammatory drugs, and strenuous exercise during treatment and follow-up. She should be informed about separation pain in the first 4 days of treatment. Success rate of medical treatment 85-92%. 

Posted by afraa A.

 

assessment of this lady will include her history of  previous pregnancies , top , and the mode of delivaries , also history of abdominal surgeries because this are risk factor for abdominal adhesions

the presence of positive history of pid or history of new partener in the last 1 year also is very imporatnt because the chlamidia tracomatis is one of the risk factor of ectopic pregnancy  presence of shoulder pain also will indicate intrabdominal bleeding

i will assess her general condition for heamodynamic instability , abdominal examination for localized tenderness and rebound tederness in the suprapubic area and illiac fossea then vaginal examination lookin for the amount of bleeding and cervical motion tenderness

i will ask for fbc , and blood chemistry ,then i will crossmatch 2 units PRBC , then the level of quantitative bhcg 

 then i will do ultrasound scan looking for intruterine gestational sac which will indicate intrauterine pregnancy . adenxial mass or fluid collection in the pouch of douglas will indicate ectopic pregnancy 

b -

non surgical mangement of ectopic pregnancy will be decided according to the patient heamodynamic stability , that means if she is having , mild symptomes and her vital signs were stable and quantiative beta hcg is less than 1000 iu/ml , with uss picture of adenxial  mass of less than 3 cm  then we may consider expectant management but this need to be sure that the patient will be complient for her follow up and she had immediate acsess  medical service , patient should be warned against signs of ruptured ectopic pregnancy 

the nice guidline recommend the expectant management for pregnancy of un known location 

medical management of ectopic is indicated if the patien is clinically stable with beta hcg lvel less than 3000 iu/ml and no intrauterine pregnancy , it is successful in more than 80 % of cases , but goos councelling regarding the methotrexate sideeffect need to be adressed to the patient clearly and also the need for good complience to follow up

methotrexate is given as 50 mg/m2 intramusculer  single dose , and it can be repeated if the the beta hcg is platuing or increasing .

the level of beta hcg need to be measured in day 4 and day 7 

there are 7% of patient have failure of medical treatment and they need surgical intervention .

methotrexate sideeffect include nausea , vomiting and abdominal pain which is encountered to some cases that need surgical intervension .

 

 

Posted by sonia J.

A healthy woman presenting with amenorrheaof 7 weeks with positive pregnancy test with pain and bleeding needs to be assessed the details of the pain and bleeding complaints.we need to know the severity of pain,onset-acute or chronic,any aggravating or releiving factors,radiation.If there are associated symptoms of nausea,vomiting,diarrhoea,syncope,shoulder tip pain.                                                                                                                        The assessment of bleeding includes the amount of bleeding,colour(bright red or dark),if the bleeding preceeded pain or vice versa. Her obstetric history, any history of infertility or treatment of infertility should be elicited . Hstory of STD and its treatment needs to be asked. The kind of contraceptive measures she must be using in the past, any surgical procedure she underwent in past needs to be documented. Ask if any ultrasound has been done earlier to confirm an intrautrauterine pregnancy.A thorogh general , abdominal, per speculum, pelvic/rectal examination can help form a provisional diagnosis. The diagnosis can be confirmed with a transvaginal ultrasound if it is an ectopic pregnany, missed, threatened, or incomplete miscarrige.                                                                                                                                                                     (B)the woman has ectopic pregnancy. The diagnosis has to be conveyed to the woman with a proper plan of management and care. Before offering the options of management we need to have the laboratoy reports of ,FBC, Urea and Electrolytes,LFT, Sr beta hCG, detailed TVS report.The nonsurgical options include expectant management and medical management. The criteria for an expectant management icludes ..asymptomatic woman..hCG level<1000IU/L,  adnexal mass <4cm, and haemodynamically stable lady with <100ml free fluid in POD.This lady is bleding and has pain so madical management can be offered if hCG<3000-5000iu/l, adnexal mass <4cm,no cardiac activity in the adnexal mass,haemodynamically stable with no or minimal bleeding. This includes giving methotrexate ,a folinic acid antagonist ,in the dose of 50mg/sqm.This treatment is offered to woman with cornual pregnancy, persistent trophoblastic disease, patient with one fallopian tube and wants to retain fertility, woman denying surgrery or not fit for surgery.This tratment is contraindicated in woman with renal and hepatic disaese,immunodeficient,breastfeeding or with active infection. After giving methotrexate ,the lecel of beta hCG are measured on day 4 and day 7.With an initial rise in hCG level ,there is a fall on day 4.A fall of about 15% is a good respone.By day 7 if the fall is less than 25%,then a repeat dose of methotrexate can be given.The respone is followed with measuring hCG level till they fall to 25IU/L. This may take 4-5 weeks.The advice with methotrxate treatment is to take plenty of fluids, avoid alcohol and sunlight and abstinence ofrcontraception for 3 months.The side effect profile includes nausea, vomiting and abdominal pain. The woman needs to be told that the need for surgery can arise anytime. The medical management is successful in about 90% cases.

Posted by geeta G.

initial assessment includes a detailed history taking, examination and investigations to reach a diagnosis.

Gynae history regarding regularity of menses, previous PID, contraceptive use including IUCD. Obstetric history for previous miscarriage or ectopic gestation or caesarean section. history regarding severity of pain and association with other symptoms including dizziness, syncope, nausea and vomitting.Nature of bleeding - fresh red or brown black in color, amount of bleeding ( heavy amount may indicate miscarriage). any bladder bowel complaints to rule out non gynae causes. review previous records as an USG in last week may have confirmed IU pregnany

Examination for general condition of patient. Vital signs including pulse, BP and respiratory rate. Abdominal examination for distension, tenderness, gaurding and rigidity. Examination of pad for any expelled products of conception. Per speculum examination for open os or any POCs in the process of expulsion. Per vaginal examination for uterine tenderness, adenexal mass, cervical motion tenderness.

Investigations include FBC and blood group with rhesus typing. Usg examination to look for Intrauterine pregnancy, any adenexal mass suggestive of ectopic pregnancy and fluid in abdominal cavity or POD

Non surgical management of ectopic pregnancy include either expectant or medical management with methotrexate, both of which can avoid risk of surgery and anaesthesia and more cost effective. Patient may feels psycologicaly better that tube has not been removed.

For non surgical methods, patient selection criteria needs to be very strict. Patient should be asymptomatic, adenexal mass less than 3 cm,bhcg levels less than 3000 IU, no cardiac activity in the ectopic mass, ready for close follow up, needs close monotoring.

Methotrexate is an antimetabolite (antifolate) and  is associated with its own side effects of nausea, vomitting and abdominal pain.Rescue with folinic acid needs to be given. Pain after administartion of methotrexate needs to be distiguished from pain of rupture. Patient anxiety is persistent till the treatment is completed.

bhcg levels may increase in first few days after methotrexate. Constant monitoring and repeat testing is required to assess resolution. Patient needs to avoid alcohol, strenous work and sexual contact while on treatment and needs to use contraception for futher 3 months. 

Non surgical management is successful in almost 90 % of carefully selected patients, but risk of rupture and further surgery does exist.

There is no difference in the rate of subsequent IU pregnancy or persistent ectopic pregnancy when compared with salpingostomy

Posted by Shahla  K.

Keeping high index of suspicion for Ectopic pregnancy ,seen in dedicated early pregnancy unit.

Need  the History indicating hypovoleamia, dizziness, any syncope attack, shoulder tip pain, passage of clots ,the severity of pain,  mild or sever, nature of pain colicky or continuous, any complaints regarding bowl, or any urinary symptoms, previous ultrasound report if done.

 History of previous pregnancies, and outcome , use of any contraception (IUCD and POP), history of previous surgeries, history suggesting of of STD ( multiple sexual partner Change partner recently, vaginal discharge )

Took any infertility treatment

General examination to see her condition pallor, BP, pulse,

Per abdominal exam for guarding rigidity, tenderness, Rebound tenderness, any mass

Per speculum exam to assess cervix, amount of bleeding

Vaginal examination, to  see stat of cervical os, cervical excitation, adnexial fullness, or mass uterine size.

Investigations include transvaginal ultrasound, If intrauterine sac and fetus seen and no adnexial abnormality (no mass , no fluid) then no further investigation required except to check haemoglobin if clinically indicated.

But if uterus look empty, then look for any adnexial  sac or mass,  and free fluid.

Suggestive of  ectopic ,  if quantitative BHCG  > 1500 IU which is above the discriminatory zone , however scan depend upon experience of operator, and  resolution of machine

But if no abnormality seen and BHCG less then discriminatory zone need repeat BHCG after after 48 hour, if Double suggestive of viable intrauterine pregnancy, failure to double suggest ectopic or failing pregnancy.

Serum progesterone level can be use as adjunct to TVS, <25ng indicate non viable pregnancy

60ng indicate intrauterine viable pregnancy

B) The non surgical options are

Only appropriate if patient general condition stable, beta hcg less than 4000 iu, adnexial mass less than 4 cm,no cardiac activity, free fluid less than 100 ml,  pt is well compliant to keep  follow up , given written information contact number in case of emergency.

Where 24 hour service available to deal with emergency

It is non invasive, less chance of pelvic adhesions, more fertility conserving, cost effective methods

Expectant management if stable general condition, BHCG  less than 1000, follow up  Quantitative BHCG twice per week and TVS after 1 week , until BHCG less than 20 IU

Success rate 90 %

Failure to fall and more than 10% of initial level require methotrixate single dose.

Medical management involve single injection of methotrixate 50 mg per meter square , then follow up of bhcg on day 4 and day 7

Repeat injection if less than 15% fall in bhcg,  14% may require 2nd dose.

Pt councilled to report if change in pattern of pain or syncope attack, as there is  7%risk of rupture ectopic,

Advised for pelvic rest from aggressive exercise, constipation and intercourse

Anti D to be given if  RH negative.

Avoid pregnancy for three months in view of teratogenesis  , contraception advice

Future intrauterine rate of pregnancy 59% with risk of recurrent ectopic pregnancy 10%

Essay 293 Posted by Sarah S.

(A)      My assessment will start by asking more about her condition. If the pain is sharp, localized to one side with possible shoulder tip pain and dizziness or syncope along with vaginal bleeding may point towards ectopic pregnancy. On the other hand, if the lower abdominal pain is relieved after passing out some tissues it may indicate a complete miscarriage. Persistent lower abdominal pain with passage of some tissue may suggest incomplete miscarriage. In addition to this I will try to obtain from her any  previous history of ectopic or  STDs or use of IUCD . on examination I will  assess the general status of the patient looking into her BP,PR, Temperature, respiratory rate. Check if got pallor, listen to the chest and cardiovascular system. examine abdominal for tenderness rebound tenderness and uterine size  I will then perform speculum examination looking for amount bleeding, cervical status and presence of products of conception(POC). If POC is at the os  may indicate inevitable miscarriage.. vaginal examination will reveal  uterine size, mobility, tenderness, adnexal mass and its tenderness. presence of cervical excitation on vaginal examination  favors diagnosis of ectopic pregnancy. I will do transvaginal ultrasound looking for intrauterine or extra uterine pregnancy, free fluid. I will send FBC, clotting profile, blood grouping and holding.

(B)         Non surgical management of ectopic pregnancy is suitable in some selected cases. These can be expectant or medical approach. Such cases should be managed in dedicated early pregnancy clinics in a dedicated area with appropriate staffing. It should be offered to those patients who are able to return for follow up and fulfill the following criteria: asymptomatic, having unruptured ectopic with an adenaxal mass that is smaller than 3.5cm with no visible heart, a serum HCG less than 1500IU/L and no intrauterine pregnancy. even though success rate of expectant and medical management vary from 48%-100% and 65-95% respectively, it needs more close follow up and emergency out of hours back up. An appropriate timing of serum HCG monitoring in the expectant group is to check every 48 hours and then weekly until undetectable with weekly transvaginal. Those on the medical management (methotraxate –MTX-) it involves giving a single of MTX and checking serum HCG on day 4 and 7posttreatment. If it drops more than 15% between day 4 and 7 then HCG is checked weekly. It can also be given in or multiple dose even though no significant difference is noted in between the 2 regimes. Rather outpatient single dose MTX is associated with a saving in treatment cost. Before embarking to the medical treatment patient should be counseled about the benefits, side effects and possible need for further treatment. The need for compliance is also emphasized. In addition, the women should be warned to avoid alcohol, sexual intercourse, folic acid during the period of the treatment. Women  have to informed what to expect and when to seek urgent treatment.

ectopic pregnancy Posted by Veera V.

a)      Early pregnancy complications such as threatened miscarriage, molar pregnancy or ectopic should be considered in this case.  A high index of suspicion for ectopic pregnancy should be maintained until proven otherwise.  Risk factors for ectopic pregnancy such as usage of mini - pill, assisted reproduction, previous ectopic pregnancy, tubal surgery, sterilisation, IUCD usage and history of pelvic inflammatory disease must be explored.

Further assessment of pain abdominal or pelvic, shoulder tip pain will suggest. Further questions about vaginal bleeding such as the existence of clots, POC like tissue, grape like tissue can help in differential diagnosis. Physical signs such as cervical motion tenderness, rebound tenderness or peritoneal signs, pallor, abdominal distention, enlarged uterus, vital signs can give us clue about the diagnosis and also the severity of the problem.  Hypotension and tachycardia can lead to shock and collapse. Ultrasound using Trans abdominal or Trans vaginal approach can help in the diagnosis by ascertaining the location of pregnancy intra/extra uterine, snow storm appearance in molar pregnancy and irregular sac or hematoma in threatened miscarriage.  . Beta HCG can give us a clue of  which  condition she is suffering from for example molar pregnancy will have very high titres of Beta HCG, threatened miscarriage can have normal beta HCG or if failing pregnancy will show sign of reduction in serial Beta HCG. Beta HCG that doubles in 48hours can indicate healthy pregnancy and a rise of less than half  would  suggest otherwise.

 

b.Non surgical management will include medical management or expectant management.

  As for medical management systemic methotrexate should be offered  for patients who are able to return for follow-up, no significant pain, unruptured ectopic pregnancy with adnexal mass less than 35mm without visible heartbeat, serum beta hcg of less than 1500IU/litre and no evidence of intrauterine preganacy. Treatment with single dose of methotrexate with calculated  dose  calculated per m2 body surface area (50mg/square meter) had shown success rate of 85 -94% . Such treatment is not expensive and does not require intensive monitoring and folinic acid supplementation compared to multiple dose regimens.This regime also has shown fewer side effects.After inhection the patient should come to monitor the fall in beta HCG and symptoms. Serum Beta HCG should be monitored at D4 and D7. If fall is less than 15% further dose  can be considered.
The patient  should be given clear written information about the possible need for further treatment and potential complications.Folowup is very important as  7% of women experience tubal rupture during follow-up. About 75% of women will experience abdominal pain following treatment.The patient is also advised to avoid sexual intercourse during treatment, maintain ample fluid intake and use reliable contraception for 3 months after treatment because of the possible terratogenic effects of methotrexate. This method is comparable with laparascopic salpingostomy with  subsequent intar uterine pregnancy rate of 54% and recurrent ectopic rate of  8-10%.
Patient must be educated  about the adverse effects  such as stomatitis, alopecia, neutropenia ,pneumonitis and also possibility of failed therapy needing to switch to surgical intervention especially if ectopic pregnancy ruptures during followup.These discussions with patient must be documented carefully. Expectant management can be offered in case where pt is asymptomatic and hemodynamically stable, beta HCG low(< 1000iu /L0 and falling trend, < 100ml blood in POD, and no fetal heart in ectopic mass.Low and rapidly falling HCG levels indicates high likelihood of successful expectant management. Twice weekly serum HCG levels and weekly transvaginal scans should be done  to ensure levels falling rapidly and size of ectopic mass decreasing. Thereafter, weekly HCG and scans until HCG <20iu

Posted by biba W.
  1. I will ensure the patient is hemodynamically stable by checking her vital signs like blood pressure, pulse rate and oxygen saturation. If she is stable, I will take a history of missed menses, vaginal bleeding and abdominal pain. I will also ask for risk factors of ectopic pregnancy like previous ectopic pregnancy, tubal surgery, pelvic inflammatory disease, use of the mini pill, intrauterine contraceptive device, smoking and assisted reproductive techniques. Abdominal exam should be done to elicit tenderness and guarding. Speculum examination to look out for vaginal bleeding and product of conception. Vaginal examination to elicit cervical motion tenderness due to hemoperitoneum. Full blood count and cross match of blood should be done. Serum beta-hcG levels should be taken for trending. Transvaginal ultrasound should be done to look for empty uterus and adnexal mass. Size of the adnexal mass should be measured, presence of fetal cardiac activity should be noted.  Free fluid in the pelvis can mean ruptured ectopic pregnancy.
  2. Non-surgical management include expectant management and use of methotrexate. Expectant management involves observing serum BhcG trend and regular ultrasound to monitor size of the ectopic pregnancy. The criteria are adnexal size less than 4 cm, initial serum bchg level less than 1000 and falling, less than 100 ml of free fluid in the pelvis, no fetal cardiac activity and patient is hemodynamically stable. Benefit is low cost, outpatient management and avoidance of surgical risks. The disadvantages are risk of persistent trophoblastic disease and tubal bleeding or rupture which will warrant an emergency surgery. Patient also needs to be compliant and return for regular followup with serum bhcg and transvaginal ultrasound. Serum bhcg needs to be repeated twice a week and transvaginal ultrasound repeated weekly till serum bhcg less than 20IU/ml and disappearance of adnexal mass. Methotrexate is a folinic acid antagonist and given as 50mg/m2 as a single intramuscular dose. The criteria are patient will be compliant with follow up and there are adequate facilities for follow up, not in significant pain, serum bhcg level less than 1500, unruptured adnexal mass less than 35mm without cardiac activity, no intrauterine pregnancy and patient is hemodynamically stable. Patient with serum bhcg level of 1500 to 5000 with the rest of the criteria have the option of methotrexate or surgical management. There is a 85 to 94% success rate. Serum bhcg will be repeated on day 4 and 7 and if there is less than 15% drop in serum bhcg levels , a second dose of methotrexate can be given. The contraindications are active infections, liver and renal abnormalities and hematological diseases. Side effects include stomatitis, neutropenia, photophobia, conjunctivitis, gastric discomfort and about 60% of patients experience increase in abdominal pain. Patient should be advised to refrain from sexual intercourse during treatment and use effective contraception for 3 months due to teratogenicity. The intrauterine pregnancy rate after methotrexate treatment is 54 % which is similar to surgery with a 8-10% risk of recurrence of ectopic pregnancy in the next pregnancy. Patient can also be treated as outpatient. However there is a 7% risk of tubal bleeding and also persistent trophoblastic disease which will require surgical management.

 

Ectopic essay - Jess Posted by Jess T.

a) The priority is to establish the stability of the patient whilst considering the differential diagnoses. Airway, breathing and circulation need to be confirmed (ABC), the heart rate, respiratory rate, oxygen saturations, blood pressure and temperature all need to be checked. If the patient is able to talk coherently then her ABC will all be in tact but she may still be unstable, hence the need to check the above observations. While this is occuring a targeted yet detailed history to differentiate between the potential diagnoses needs to be taken (ectopic pregnancy, miscarriage, appendicitis, pyelonephritis, ovarian cyst accident); onset, sit, radiation and character of the pain, any associated symptoms such as nausea, vomiting, diarrhoea (commonly present with ectopic pregnancy) and urinary symptoms. Degree of PV bleeding, association with pain. Shoulder tip pain? Obstetric and gynae history including parity, past pregnancy outcomes, cervical smear history, hx of PID/endometriosis/contraceptive use/previous abdominal or pelvic surgery/fertility treatments (all risk factors of ectopic pregnancy). Relevent past medical or surgical history, smoker?

An abdominal and vaginal (with consent) examination needs to be performed, looking for tenderness, cervical excitation, mass in pelvis, degree of PV bleeding and whether cervical os is open.

Investigations would include a blood hCG level, and an ultrasound scan (ideally TV) - is there an intra- or extra-uterine pregnancy or no pregnancy seen? any free fluid/adenexal masses? Bloods to check blood group and rhesus status should be sent for group and save, haemoglobin level and white cell count. U&E and LFTs may be indicated (especially if considering surgery or methotrexate treatment).

b) Non-surgical management (aiming for tubal preservation) refers to expectant management (conservative) and medical management with methotrexate. Expectant management may be appropriate in cases of pregnancy of unknown origin (PUO) or tubal ectopic in a clinically stable patient with minimal symptoms and a hCG of <1000iu/L. They require close monitoring and serial hCG measurements and need to be aware that approximately 50% of PUOs will resolve in this way whilst about 25% will evolve into identifiable ectopic pregnancies which may require further treatment. It is successful in up to 60-80% of cases and a rapidly falling hCG is an indicator of good outcome. Methotrexate management (50mg/m2 IM) is inidicated in clinically stable patients with minimal symptoms, with a hCG <3000-5000 iu/L (dependent upon the unit), no FH seen on USS and minimal free fluid.Most patients will require on 1 dose although 15% will require repeated doses and <10% will require surgical intervention but patients need to be aware this is a risk and emergency surgery is a risk. Side effects such as GI disturbance and abdominal pain need to be made clear and patients need to be aware of the need to delay a future pregnancy by 3 months after treatment due to the anti-folate effect.

Developments of alternatives to methotrexate are being considered, such as the use of Gefitinib.

All women with a suspected ectopic who are rhesus D negative require anti-D immunoglobulin if not previously sensitised.

Posted by afraa A.

Dear I.T  Admin 

 I have problem with browsing this discussion page and i think it is related to the site , would you please fix it if possible 

thanks 

GV Posted by Vandana G.
Ectopic Answer 293 In a reproductive age lady with positive pregnancy test and acute pain abdomen, ectopic pregnancy should be ruled out. Our initial assessment should include a quick history about details of pain-- severity, radiation to shoulder tip and aggravation by movement. Regarding vaginal bleeding enquire about quantity of bleeding and passage of any products of conception. It is suggested that in ectopic pregnancy pain precedes bleeding. Gynaecologic obstetric and contraception history is asked with special attention to risk factors of ectopic pregnancy. General examination with measuring of vitals ( pulse, blood pressure & temperature) helps assess the blood loss. Abdomen is examined for tenderness which may be seen in ectopic pregnancy, pelvic inflammatory disease or appendicitis. Guarding or any positive finding on per abdomen examination may not be present.
ectopic pregnancy IE Posted by IE M.

A -The most likely deferential diagnosis are ectopic pregnancy, miscarriage and molar pregnancy.

Assessment  is by history , examination, and investigation. To know stability of the patient Ask about any dizziness or feeling drowsy .  Asking about the nature of pain constant or colicky. Asking about the amount of the bleeding  any clots or tissue which suggest miscarriage. Grape like material suggest molar. Ask about risk factor for ectopic like previous ectopic , IUCD, mini pill or previous tubal surgery. Examination by measuring BP, P and Temp. to know whether stable or not. Examine mucous membrane for palor, dehydration. Abdomen for tenderness or distention or rebound tenderness.  pelvis for adenexal masses or tenderness. Speculum examination to see cervical dilatation or clots. Per vaginal examination to see dilatation and any motion tenderness . Investigation by FBC to see if anaemic. Group and safe, LFT and urea and electolytetes as base line. Trans vaginal ultrasound should be done to look for intrauterine or ectopic  pregnancy. Any retained product of conceptus. BHCG   for base line for repeat after 48 hours.

B- non surgical treatment include  medical treatment  need the patient to be stable without significant pain, and patient to comply with follow up. also special criteria needed  like BHCG less than 1500 iu|l, adenexal mass less than 35 mm without heart beat, fluid in Doglus of pouch less than 100ml. medical treatment by methotrexate injection can be given. Advantages  of medical treatment : it is cheap and easy. Avoid hospital admission. Avoid surgery with its complications of bleeding and tissue injury. Avoid general anaesthesia. Less risk of infection. Effective success and tubal patency 85 to 94 %. Cost effective and less hospital stay. Can be used for serious places of ectopic like abdominal and coronial ectopic pregnancy. Better for patient with one tube or a diseased other tube.

Disadvantages of medical treatment are that the  patient can experience pain, and there is a high risk of rupture ectopic , which carry an increased risk of mortality. Anxiety . Failure of treatment can occur. Need for further surgery may occur. second dose may be needed. Methotrexate is a teratogenic drug so no pregnancy for three monmth after treatment. Side effet of the drug like stomatitis, alopecia, neutropenia, and GI symptom. Gestesional  trophoplastic disease can occur. Need for more follow up for BHCG which disturb the patient .  

Posted by farzana S.

Dear IT department,

Now the discussion page is ok,but I can not find my answer.Where did it disappear?

Dr Farzana.

beta hcg value Posted by celine  S.

Dear sir,

The greentop guideline no.21,on tubal pregnancy pg.4 suggests methotrexate therpy is suitable for women with s.betahcg below 3000i.u/l and minimal symptoms.

I did not find my answer Posted by IE M.

Dear dr paul

I sent my answer  ectopic pregnancy 392 but I did not find I want it may be deleted?y

I sent it again please mark it for or tell me reason for deleting it

IE

 

Posted by Ida I.

a)

History of lower abdominal pain, PV bleeding and positive pregnancy test is suggestive of ectopic pregnancy. History of passing out POC in the presence of pain and PV bleeding is suggestive of a miscarriage. Previous history of pelvic inflammatory disease, previous ectopic pregnancy, IUCD use, smoking and progesterone-only pill should be asked to assess her risk factors for an ectopic pregnancy.  Her blood pressure, pulse rate and oxygen saturation should be taken to assess her hemodynamic status. Abdomen palpated for tenderness and guarding that would suggest and intraabdominal bleed. Vaginal examination should be done to elicit cervical motion tenderness that would suggest intra abdominal bleeding. Speculum examination done to look for presence of POC at the cervical os and exclude miscarriage. Transvaginal ultrasound done to localise pregnancy, and for any presence of adnexal masses and fluid in the Pouch of Douglas. Full Blood Count taken for baseline hemoglobin level. BHCG level taken as baseline.

b)

She can be managed expectantly if she is asymptomatic with a BHCG less than 1000IU/L at presentation with no cardiac activitiy and an adnexal mass of less than 5cm on TVS. However, as she presents with pain, expectant management would not be a suitable option in this patient.

Medical management of ectopic is with Intramuscular Methotraxate, given as a single dose at 50mg/ m2 body weight. This can be considered if she has minimal symptoms, BHCG less than 1500 IU/L at presentation and an unruptured ectopic with an adnexal mass less than 35mm with no cardiac activity detected. It is cost effective, can be done as an outpatient basis, and saving the cost of hospital stay and treatment. BHCG levels are taken on days 4 and 7 to assess treatment response. Methotraxate has a success rate of 85-90%, with only 15% of women needing more than one dose. Thus, making this an acceptable form of treatment among patients. However, Methotraxate has distressing side effects. Most will experience abdominal pain, causing them to be admitted for observation and repeat transvaginal to exclude a ruptured ectopic. Other adverse side efects include stomatitis, conjunctivitis and gastrointestinal upset. She should be advised to abstain form sexual intercourse, take ample fluid and to use reliable contraception during treatment. She should also be advised not to conceive within 3 months after methotraxate treatment for fear of teratogenicity. She should be given oral and written information about the possible need for further treatment and its side effects. She should be able to return for assessment at any time during follow up.

sma Posted by shah M.

Ectopic pregnancy

Assessment is done by history,examination and initial investigation.history of severity, onset ,nature(colicky,continous) of pain and bleeding –severity ,clots is asked .history of shoulder pain,epigastric pain to rule out peritoneal irritation due to intraperitoneal haemorrhageand syncope to rule oiut cardiovascular unstability ,associated symptoms-nausea/fever/dysurea to rule out appendicitis,PID.menstrual history-regularity to ascertain gestational age.Risk assessment for ectopic pregnancy- history of tubal disease by previous history of ectopic pregnancy, PID,tubal surgery, contraceptive history POP/iucd.Examination for her general condition including alertness, Pallor,  vitals    Pulse rate,blood pressure,respiratory rate, temperature to assess cardio respiratory stability,.Abdominal examination is done to rule out distension (internal bleeding),guarding ,rebound tenderness to rule out peritonitis.Local and speculum examination to assess severity /ongoing bleeding and to rule out local causes of bleeding-l ulcer/ectropion.pelvic examination to assess cervical excitation may cause rupture of ectopic ..so done gently only if needed. Initial investigation like full blood count, group and save, to determine  blood transfusion,Serum beta hcg and Trans vaginal ultrasound will be done to rule out ectopic pregnancy.

B.

Nonsurgical management include expectant and medical  (Inramuscular(methotrexate)management .

Benefits of nonsurgical management avoids  anaesthestic   risks like( cardiorespiratory arrest- GA and,hypotension,infection –regional anaesthesia)/surgical risks like bleeding,visceral-bowel,great vessel ,ureter injury,infection).however both increases anxiety due to awaiting. Both expectant and medical treatment may fail necessitating surgical management.

expectant management is possible ony in asymptomatic  , stable patient  with unruptured, non viable ectopic,minimal fliud in POD and initial Serum b hcg- less than 1000iu/l and adnexal mass less than 35mm.she must be able /willing for regular follw up and for emer gency surgery in case of rupture ectopic pregnancy.she needs to have twice weekly b hcg and weekly TVS initially till b hcg starts declining there after weekly hcg and TVS monitoring till hcg is undetected/less than 20 iu/l.Medical management is possible ony in asymptomatic  , stable patient  with unruptured, non viable ectopic,minimal fliud in POD and Serum b hcg- less than 1500iu/l and adnexal mass less than 35mm.she must be able /willing for regular follw up and for emer gency surgery in case of rupture ectopic pregnancy.she needs to have twice weekly b hcg and weekly TVS initially till b hcg starts declining there after weekly hcg and TVS monitoring till hcg is undetected/less than 20 iu/.Intra muscular Methotrexate(50mg/m2 is given either in single or multiple doses if initial fall in s.beta hvg level is less than 15% between day 4 and day7.Methotrexate is an antimetabolite and has got side effect like sore throat, osteopenia ,gastro intestinal disturbance and hepato/renal toxicity.It causes significant abdominal pain in 75% of women within 24 hrs of administration- may mimick rupture of ectoic pregnancy.success rate is about 80%. After methotrexate she has to avoid pregnancy for 3 months for next pregnancy to avoid teratogenecity. Future intra uterine pregnancy rate is comparable to surgical treatment(salpingostomy and salpingectomy).

Posted by farzana S.

Dear IT department,

Microsoft Word was not working well in my laptop,so we installed Kingsoft writer.where I write and then paste. ,and we have Windows 7.

This probably is the reason for problem.Should I write my answer directly in this space? .my email id is dr_farzananaheed@yahoo.com .

Dr Farzana

Posted by aysha Z.

The main aim of this assessment would be ascertain the stability, condition and then cause of the pain. I would ensure that she was alert with no risk to her airway. Tachycardia and hypotension would alert me to cardiovascular compromise. IV acess along with a haemaglobin, Beta HCG and cross match of blood wouild be obtained.

My history would then discuss the causes of the pain. The main. cause is an ectopic pregnancy, however if miscarriage and ovarian cyst accidents could also present with this. Questioning on symptoms such as the duration, nature and site of the pain would be followed by the questions on the quantiy of bleeding, also if symptoms such as shoulder tip paain and diarrhea are present.    I would elict risk factors for ectopic such as previous STI or PID, tubal surgery or previous ectopic. Examination of the abdomen would idenitify tenderess, distension or perionitis. A vaginal examination with examination of the cervical os could differeniate bewteen an ongoing miscarriage or an ectopic.  A bimaual examination would elcit cervical tenderess and adnenxal massses or tenderness which could point towards an ectopic. If the patient was stable, I would arrange an urgent ultrasoun d assessment. 

 

NICE guidance does encourage the role of conservative and medical management of miscarriage. If used correctly this  is more cost effective and has reduced risks to the woman rather than laparascopy

. Medical managment is performed using methotrexare. A dose is calcuated according the patient's weight and height. There are specific critieria for offering medical manangment. This includes the patient to be cardio vascuarlsy stable, for her not to be in severe pain. If there is a confirmed ectopic it must be small (?<2cm) and her beta HCG less than 3000. It must explained that there is a cytotoxic drug and that she will need repeat beta HCG monitoring.  She must be made aware that she is to seek medical attention if she experinces severe pain or becomes unwell. 

 

The main advantage of the methotrexate is an ectopic can be treated without the patient undergoing the aneaesthic risk and operative risks of laparascopy. As the medical treatment is outpatient this reduces the cost burden to the NHS. 

For a lot of women the main disadvantage of mextotreate is the advice they are not to conceive for 6 months due to the tetragenic properties of mextotreate. There is also a small risk of the patients still requiring surgical managment after adminstration of mextorexate. Another disadvantage of methotrexate is the side effects including mouth ulcers. 

Conservative manangment of moniotoring beta HCG is used only for a small proportion of women who are completely asymptomatic and have low and falling beta HCGS. These women are also managed at home and are given advice to seek medical attention if they have pain or feel unwell. This too has the cost effectiveness of being outpatient and also reduces the patient's risk of laparascopy. 

 

essay 293 Posted by wafa T.

assessment .

I will take detalied history about  pain severity , site of painand   if  it is associated with pain in the shoulder or bladder and bowel symptoms as pain on defecation . I will ask also about severity of her bleeding  and also if associated with passage of blood clots or tissues. If she has previous history of pelvic inflamatory disease , previous ectopic pregnancy , contraceptionshistory  .and whether she had syncopal attack or fainting?.

Examination . 

Iwill check her pulse for tachycardia , blood pressure , o2 saturation . Abdominal examination to check . tenderness or rigidity.Speculum examination  to exclude local cause in the cervix and whether cervix open with product of conception  come out  cervix in case of inevitable miscarrage . Pelvic examination, to exclude pelvic tenderness , adnexal tenderness ,or cervical motion tenderness . 

investigations .Blood sample should be send for full blood count  , group and save , renal and liver function test , coagulation screen and serum beta hcg.  Transvaginal ultrasound to  determine intrauterine orextrauterine pregnancy ,whether there is adnexal mass and how much its size , also if ther is free fluid in pouch of douglous.

Managment.

Medical managment  with methotroxate will be if unruptured ectopic pregnancy with adnexal mass less than 3.5 cm and no visible  fetal cardiac beat ,no significant pain ,serum hcg 1500 - 5000iu/lit ,Patient   must  accept follow up. Dose of methotraxate is 50 mg / m square body surface area .The advantages of methotrxate are cheap , avoid surgical interventions  ,sucess rateis 85-90%,total pregnancy rate after treatment is 54% and tubal patency is 80% .Follow  up with beta hcg on day 4 and day 7 .there is initial increaseof serum beta hcg then dcerease of serum level at least 15% on day 4-7  . If no decrease second doseof methotroxate is needed . Side effects of methotrxate are associated with abdominal pain in 75% of patient, alopecia , mucosal ulceration, photosenstivity and luecopenia . there is risk of rupture ectopic pregnancy 8--10% with treatment with methotrxate . Advice to patient to take more fluid , avoid intercoruse and avoid expousre to sun light .Follow up with serum beta hcg weekly till level become less than 20 iu/l

Written information should be given to the patient.

Test Posted by Farrukh G.

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Title Posted by Farrukh G.

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Posted by Lubna O.

293

GV Posted by Vandana G.
Ectopic Answer 293 In a reproductive age lady with positive pregnancy test and acute pain abdomen, ectopic pregnancy should be ruled out. Our initial assessment should include a quick history about details of pain-- severity, radiation to shoulder tip and aggravation by movement. Regarding vaginal bleeding enquire about quantity of bleeding and passage of any products of conception. It is suggested that in ectopic pregnancy pain precedes bleeding. Gynaecologic obstetric and contraception history is asked with special attention to risk factors of ectopic pregnancy. General examination with measuring of vitals ( pulse, blood pressure & temperature) helps assess the blood loss. Abdomen is examined for tenderness which may be seen in ectopic pregnancy, pelvic inflammatory disease or appendicitis. Guarding or any positive finding on per abdomen examination may not be present. Per speculum examination is performed if the patient is stable to rule out any local cause for bleeding. Per vaginum examination is useful to assess that cervical os is open, know the uterine size, may ellicit cervical motion tenderness in ruptured ectopic or pelvic inflammatory disease. Sometimes adnexal mass or unilateral tenderness may also be palpable in ectopic pregnancy. The investigation of choice is transvaginal ultrasound and if inconclusive serum beta-hCG, repeated after 48 hrs will help in the diagnosis. The non-surgical options for management of ectopic pregnancy are expectant and medical treatment. Expectant management is suitable if patient is asymptomatic, stable and serum beta-hCG is less than 1000mIU/ml. Medical management is an option if the patient is stable, hemoperitoneum or free fluid is less than 100 ml, adnexal mass is less than 4cm and no cardiac activity is detected. Single intramuscular injection of methotrexate according to body surface area, 50mg/m2, is an appropriate treatment. Patient is followed up with serum beta hCG on day 4 & 7 of the injection and then till beta hCG is less than 25IU/ml. If the fall in beta hCG is <15% on day 4 or <25% by day 7, a repeat dose of methotrexate may be considered. The patient opting for non-surgical management should be given written information about a 24hrs emergency contact number and need to return in case of excessive pain, bleeding or fainting. The patient receiving methotrexate is advised to avoid alchohol & sunlight during treatment. Patient should also be advised to avoid intercourse during treatment, take ample fluids and avoid pregnancy for 3months of injection due to its teratogenic effects. The future intrauterine pregnancy rates after medical treatment are similar to surgical treatment. Only a few (15%) may require emergency surgical intervention due to rupture or repeat injection for persistent ectopic.