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MRCOG PART 2 SBAs and EMQs

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notes334
EMQ1480
SBA2068
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tubal pregnancy

tubal pregnancy Posted by Sunitha P.



Critically appraise the treatment options for a confirmed tubal pregnancy

There is an increase in the incidence of ectopic pregnancy in U.K. It form 10% of direct cause of maternal death. Once the diagnosis of tubal pregnancy is confirmed an initial assessment of the general condition of the patient is made. If the patient is in shock arrangements for immediate laprotomy with a senior obstetrician and consent is made. If the contra lateral tube is healthy salphengectomy is done. Blood less can be simultaneously replaced as the surgery is one. If the contralateral tube is absent or unhealthy salphingtomy is done. The complications of this procedure like recurrent ectopics 12%, persistence of trophoblastic disease 15% with a recurrent intrauterine pregnancy of 55% explained. The need for follow up assured and consent obtained. A laprascopic approach decreased the postoperative morbidity like stay, pain, analgesic use and less expensive with the advantage of less adhesion . The option of salphingetomy with IVF is also offered to the patient, although salphengotomy of ipsilateral tube inspite of the disadvantages is cost effective. There is no difference in the outcome if the like is being situated or not stable a transvaginal ultrasound and serum betahcg is arranged. If the findings of < 3 cm size adnexal mass, no fetal heart present and big values less than the discriminatory gone of 1500 IV expectant management continued after consent. A decrease in BHCCS after 48 hours forwards as to continue the same. However the complications of sudden rupture follow up till the values are < 20 iv/ml should be clearly explained to the family.

If the BHCG values are over 3000 iu but less than 10,000 iv medical management with the anti metabolite methotrexate with the antimetabolite methotrexate is offered. This caused autolysis of the trophoblastic tissue. A single dose of 50mg/m2/kg given im. It has the advantage of being cheap. Effective no need for folinic aid. The serum BHCgs are taken on days 4 and 7. If there is < 15% of fall in values it should be repeated. It has an efficacy of 85-95% with failure rate being 8%. There is a 80% preservation of tubal morphology. Methotrexate can be given directly into the sac with ultrasound guidance or through a laproscope. There is a higher failure rate in the former. A systemic administration has 10% chance of side effects like stomatitis, alopecia, hydrosalphinx, and GI disturbance when local administration is chosen. Pregnancy should be avoided for 6 months after its use due to the teratogenic effect.