​Kembara Xtra - Medicine - Ectopic Pregnancy

​Kembara Xtra - Medicine - Ectopic Pregnancy 
Introduction 

Ectopic pregnancy is a pregnancy that develops outside the uterus.

Included among the subtypes are: Tubal: pregnancy implanted in any area of the fallopian tube. Pregnancy implanted intra-abdominally, most frequently following a tubal abortion or tubal ectopic pregnancy rupture. Pregnancy that is heterotopic is one that is both intrauterine and external to the uterus. Pregnancy implantation in ovarian tissue. Pregnancy implantation in the cervix. Pregnancy implanted within the wide ligament is referred to as intraligamentary.

Epidemiology Incidence It is challenging to determine the actual incidence. Incidence in the United States is most likely between 6 and 20 per 1,000 pregnancies. Ectopic pregnancies account for about 1 in 10 first-trimester pregnancies that arrive to the emergency room with pain and/or bleeding. Ectopic pregnancy is the main reason for first-trimester maternal fatalities in the United States.
Although heterotopic pregnancy is uncommon (1:30,000), it happens more frequently (1/1,000) among women who get in vitro fertilization (IVF). This is partly because there are more cesarean sections performed and IVF is becoming more popular.

33% chance of recurrence if previous ectopic pregnancy

Pathophysiology and Etiology 
95–97% of ectopic pregnancies take place in the fallopian tube, with the ampulla accounting for 55–80% of these cases, the isthmus for 12–25%, and the fimbria for 5–17%. Lack of migration of the fertilized ovum into the uterine cavity as a result of tubal cilia failure, scarring, or tubal lumen narrowing is one risk factor for a tubal pregnancy.

Risk Elements 
Endometritis, current gonorrhea/chlamydia infection, history of pelvic inflammatory disease (PID), pelvic adhesive disease (infection or prior surgery), or endometritis
Previous ectopic pregnancies and tubal surgery (around 33% of pregnancies following tubal ligation are ectopic).
Use of an intrauterine device (IUD) lowers the absolute risk of ectopic pregnancy, but there is a higher chance that the pregnancy will take place in an ectopic location.
Utilization of reproductive technologies
Smoking; people who suffer from conditions that impair ciliary motility (such endometriosis or Kartagener) may be at higher risk.

Prevention 
Reliable contraception or abstinence, as well as testing for and treating STIs (such as gonorrhea and chlamydia), which can result in PID and tubal scarring, are all recommended.

Introducing History 
The traditional trifecta of sudden-onset abdominal discomfort, irregular or absent menstruation, and severe vaginal bleeding occurs in more than 50% of cases. Other typical signs and symptoms include nausea, vomiting, vaginal bleeding, and shoulder pain (from hemoperitoneum).

clinical assessment 

 Tenderness in the abdomen; Rebound tenderness related to vaginal bleeding; Palpable mass on pelvic exam (adnexal or cul-de-sac fullness); Tenderness in the cervical motion
Pallor, tachycardia, and hypotension are common indicators of shock in rupture instances with considerable intraperitoneal hemorrhage.

Multiple Diagnoses 
Missed, looming, unavoidable, or finished abortion (miscarriage), gestational trophoblastic neoplasia (also known as "molar pregnancy"), appendicitis, salpingitis, PID, ruptured corpus luteum or hemorrhagic cyst, benign or malignant ovarian tumor, ovarian torsion, cervical polyp, malignancy, trauma, or cervicitis.


Laboratory Results 
Initial Examinations: CBC, ABO type, and antibody screening
Transvaginal ultrasound (TVUS) is the preferred method of diagnosis:
– When serum human chorionic gonadotropin (hCG) levels are above the discriminatory range (>1,500 to 2,000 IU/L), the absence of a normal intrauterine gestational sac signals an abnormal pregnancy of unknown location (PUL).
– In clinical practice, there is a 99% chance of finding a normal intrauterine gestational sac when the hCG level is 3,500 IU/L. Multiple gestations are not validated for these values.
● Check hCG if TVUS is not available or is inconclusive for intrauterine pregnancy (IUP) Every 48 hours, serial quantitative serum levels typically rise by at least 53%:
A workup for gestational anomalies should be initiated by an abnormal rise (35%). Until disproven, the clinical impression of acute abdomen/intraperitoneal hemorrhage associated with a positive hCG level suggests ectopic pregnancy.
If TVUS is available, MRI may also be helpful but is more expensive and infrequently utilized; benefits include those for abdominal or cesarean scar pregnancy.
Tests in the Future & Special Considerations
A reduced risk of ectopic pregnancy is connected with serum progesterone levels >20 mg/mL. Serum progesterone levels 3.2 ng/mL in women with pain and/or bleeding who had an inconclusive US ruled out a viable pregnancy in 99.2% of women; may provide extra information for PUL but does not foretell ectopic pregnancy (1)[B] Diagnostic Procedures/Other
In the case of an unintended pregnancy, endometrial biopsy or D&C sampling of the uterine cavity can determine if intrauterine chorionic villi are present or absent. Within 48 hours after a curettage-assisted IUP evacuation, hCG levels should have decreased by 50%. Prior to surgical care in the past, culdocentesis was carried out to confirm a possible hemoperitoneum. For the time being, TVUS quantification of pelvic fluid is enough.
Test interpretation: Chorionic villi and other products of conception (POC) outside the uterus

Administration of Medicine 
Methotrexate is used to treat POCs that remain after laparoscopic salpingostomy or unruptured tubal pregnancy.
By deactivating dihydrofolate reductase, methotrexate prevents DNA synthesis by folic acid antagonistic mechanisms.
Confirm probable US results with 2 hCG levels drawn 48 hours apart in the hemodynamically stable patient who qualifies for medical therapy if TVUS is suggestive but not diagnostic. Rise of 35% or less is indicative of an unviable pregnancy.
● Most effective when hCG is 5,000 mIU/mL, pregnancy is 3 cm in diameter, and there is no fetal heartbeat visible.
Success rate is 88% if hCG is less than 1,000 mIU/mL, 71% if it is between 1,000 and 2,000 mIU/mL, and 38% if it is between 2,000 and 5,000 mIU/mL.
– There are three major dosage schedules, however single-dose schedules are recommended because to their simplicity, safety, and effectiveness as compared to multidose schedules:
Single: IM methotrexate 50 mg/m2 of body surface area (BSA); repeat if hCG levels drop by 15% between days 4 and 7 of treatment. Weekly hCG updates.
Double dosage: methotrexate 50 mg/m2 of BSA given once, then administered again on day 4. If there is a 15% fall in hCG between days 4 and 7, the third dose may be given again on day 7.
Repeat hCG as necessary on days 11 and 14 until the interval drops by more than 15%, and then do so every week. If the weight does not drop by day 14, suggest surgical intervention.
 Multidose: leucovorin 0.1 mg/kg IM in between methotrexate 1 mg/kg IM/IV doses every other day.
Maximum 4 doses until the hCG level drops below 15%; if necessary, the course may be repeated 7 days after the last dosage.
- Contraindications include immunodeficiency, moderate to severe anemia, severe hepatic or renal dysfunction, hemodynamic instability, or any sign of rupture.
– Relative contraindications include fetal cardiac activity, a big gestational sac (more than 3 cm, less effective), noncompliance, inability to travel to a hospital, and hCG levels above 5,000 mIU/mL.
Immunologic, hematologic, renal, GI, hepatic, pulmonary, or interfering medicines are concerns.
Pretreatment evaluations include blood type and screen, CBC, liver and kidney function tests, and serum hCG.
Patient counseling: Limit alcohol, aspirin, NSAIDs, and folate supplements during medication (decreases methotrexate efficacy); limit sun exposure excessively owing to risk of sensitivity. It's crucial to keep your appointment for follow-ups. During treatment, abdominal pain may get worse; however, extreme pain, nausea, vomiting, bleeding, dizziness, or lightheadedness may be signs of a failed treatment and call for immediate evaluation.
Between 7% and 14% of ectopic pregnancies rupture while taking methotrexate.
Stomatitis, conjunctivitis, abdominal discomfort, and—rarely—neutropenia, pneumonitis, or alopecia are a few of the side effects. There is limited data, but certain nontubal ectopic pregnancies may be treated with systemic methotrexate.


Referral 
If you are not knowledgeable in medical management or need surgical care, think about consulting a gynecologist.

Further Treatments
The doctor or patient may decide that surgery is the best course of action, and post-operative hCG should determine whether more methotrexate is necessary.
Surgery is required following indications of medical failure or tubal rupture.
Treatment for ectopic pregnancies in the cervical, ovarian, abdominal, or other regions is challenging and necessitates prompt specialized referral.
Follow all patients receiving medical treatment until their hCG level reaches zero to make sure no surgical intervention is required.
All Rhnegative women who undergo surgery to treat an ectopic pregnancy or if there has been significant bleeding or abdominal pain should be given anti-D Rh prophylaxis at a dose of 50 g. Expectant management of ectopic (confirmed on TVUS) pregnancy may be provided to women who are clinically stable and have low and decreasing hCG levels initially 1,500 mIU/mL. Even with extremely low hCG levels (100 mIU/mL), tubal pregnancies can rupture.

Repeat TVUS every week (or whenever hCG rises over the discriminating zone) until the location is established or the clinical picture becomes unstable when using expectant treatment of PUL.

Surgical Techniques 
A ruptured ectopic pregnancy, an inability to follow up medically, a prior tubal ligation, a tubal condition that is known to exist, a heterotopic pregnancy at the time of diagnosis, and a desire for permanent sterilization are examples of indicators.
Salpingectomy (tubal removal) is recommended and indicated for uncontrolled bleeding, recurrent ectopic pregnancy, severely damaged tube, big gestational sac, or patient's wish for sterilization. Laparoscopy is the first-line surgical therapy.

Patients who want to maintain their fertility may want to consider salpingostomy (tube preservation), especially if the contralateral tube is damaged or nonexistent. No variation in recurrence rate from salpingectomy.
In 4–15% of instances, persistent trophoblastic tissue with salpingostomy is still present in the fallopian tube; this requires weekly hCG injections.
The first line of treatment for cesarean and cornual pregnancies is surgery.

Admission 
Failure to meet the requirements for managing methotrexate, suspicion of rupture, orthostatic hypotension, shock, and severe stomach discomfort needing IV narcotics
When a diagnosis is unclear, especially when a patient is untrustworthy, inpatient observation may be necessary.
Emergency surgery If there is a chance of a rupture, two IV access lines should be set up right away, along with intensive resuscitation if necessary. En route to the operating room, if necessary, administer blood products. Pressors and cardiac assistance may be required in shock patients.
IV fluids are not necessary for the medical management of a stable ectopic pregnancy, but they are vital for the care of a surgical patient who is bleeding.
Strict input/output, hourly vitals, orthostatics if moving around, routine abdominal checks, serial hematocrit, and pad counts in the event of significant vaginal bleeding are all recommended.

 Afebrile, stomach pain subsiding or resolved, confirmed diagnosis, surgical intervention, and full recovery are the requirements for discharge.

Patient Monitoring for Continuous Care
Serial quantitative hCG measurements in the serum should be performed until the level reaches zero after methotrexate delivery. After salpingostomy, weekly amounts are suitable. Additional follow-up may not be required following a salpingectomy.

Pelvic ultrasound for recurring or chronic masses
Liver and renal function tests every week after methotrexate administration if repeat dosing is necessary Delay of subsequent pregnancy for at least 3 months after methotrexate treatment due to teratogenicity (folate deficiency) Pain control: brief course of narcotics usually necessary with medical or surgical management

Diet 

Because they interfere with the effectiveness of methotrexate, avoid alcohol, leafy greens, liver, and edamame during therapy.


Patients should be urged to plan further pregnancies and seek early medical attention upon learning of future pregnancies, and the signs and symptoms of ectopic pregnancy should be revisited.

Future fertility relies on fertility before the ectopic pregnancy and the degree of tubal impairment. Chronic ectopic pregnancies are uncommon and are treated by surgically removing the fallopian tube. Future fertility rates are unaffected by treatment options in women with normal fertility. Treatments such as pregnancy or medical interventions improve future fertility in women who are subfertile.

If they are able to conceive, 66% of women with a history of ectopic pregnancy will go on to have an IUP.
If infertility continues for more than a year, the fallopian tubes should be examined.

Complications 
Blood transfusions with concomitant infections or transfusion reactions, residual trophoblastic tissue following medical or surgical care, hemorrhage and hypovolemic shock, infection, infertility, and disseminated intravascular coagulation in the presence of major hemorrhage

---