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Figure 9-3 Management of suspected ectopic pregnancy (Adapted, with permission, from uptodateonlinecom Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation by Togas Tulandi and Haya M Al-Fozan)
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Section III: Topics in Obstetrics
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What are the treatment options for an ectopic pregnancy
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Methotrexate (for early, unruptured, ectopic pregnancies) Surgery (laparoscopy with salpingostomy or salpingectomy)
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What are the contraindications of methotrexate used to treat an ectopic pregnancy
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Active hemorrhage Pregnancy larger than 4 cm Breastfeeding Alcoholism Peptic ulcer disease Liver or renal disease Blood dyscrasias Immunodeficiency Active pulmonary disease
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What is methotrexate s failure rate What are the two methods of methotrexate administration for the treatment of an ectopic pregnancy
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5 10%, but higher in more advanced pregnancies Give a single intramuscular (IM) dose of methotrexate and then follow -hCG levels at days 4 and 7 hCG levels should decline by 15% between days 4 and 7 Alternate day IM administration of methotrexate until -hCG level decreases by 15% in 48 hours
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What are the differences between a salpingostomy and a salpingectomy
Salpingostomy: an incision is made on the antimesenteric part of the fallopian tube and the POCs are evacuated The incision is closed by secondary intention Salpingectomy: a tubal resection that involves partial removal of the oviduct, salvaging as much as possible
What is the discriminatory zone
A range of b-hCG levels (1000 2000 IU/L) in which a gestational sac should be seen if there is an intrauterine pregnancy If no sac is seen at -hCG levels above the discriminatory zone, an ectopic pregnancy can be diagnosed in most cases Both the ultrasound and the -hCG should be repeated in 3 days If the pregnancy is intrauterine and viable,
How should a patient with a low b-hCG without a visible intrauterine pregnancy be managed
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9: Complications of Pregnancy
the b-hCG should double in 15 2 days Does a negative pelvic ultrasound rule out the diagnosis of an ectopic pregnancy What is the difference in progesterone levels between an intrauterine and an ectopic pregnancy No, an extrauterine pregnancy is visualized in only 50% of ectopic pregnancies Serum progesterone levels are lower in ectopic pregnancies compared with viable intrauterine pregnancies However, the sensitivity and specificity of progesterone levels are too low to make it a screening or diagnostic test for ectopic pregnancy Approximately 18%
What percentage of patients with an ectopic pregnancy experience tubal rupture In a patient with an ectopic pregnancy, what are the risk factors for tubal rupture
History of tubal damage/infertility Induction of ovulation Never having used contraception High -hCG
How does the presence of an ectopic pregnancy affect subsequent pregnancies
It reduces the chance for a successful pregnancy A repeat tubal pregnancy occurs in 12% of patients
GESTATIONAL TROPHOBLASTIC DISEASE Introduction
What is gestational trophoblastic disease (GTD) What are the types of GTD A group of tumors that arise from placental tissue and secrete b-hCG Hydatidiform mole Persistent/invasive gestational trophoblastic neoplasia (GTN) Choriocarcinoma Placental site trophoblastic tumor (PSTT) Which of the types of GTD are benign and which are malignant Hydatidiform moles are usually benign, whereas invasive GTN, choriocarcinoma, and PSTT are all malignant
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Section III: Topics in Obstetrics
What are the major risk factors for GTD When should GTD be suspected clinically What are the signs and symptoms of GTD
Extremes of maternal age History of prior GTD If there is unusual bleeding after a pregnancy or abortion First trimester bleeding Uterine size/date discrepancy Pelvic pressure or pain First trimester preeclampsia Higher -hCG than expected Hyperemesis gravidarum Hyperthyroidism Passage of hydropic (grape-like) vesicles
What is the differential diagnosis of GTD
Normal pregnancy Spontaneous abortion Preeclampsia Placenta previa Placental abruption Endometriosis Ectopic pregnancy Ovarian tumor Prolapsed fibroid Cervical neoplasia
How should post-pregnancy bleeding be investigated
Using curettage, serum hCG measurements, and a chest x-ray (CXR) (to assess if there are nodules associated with metastasis) hCG levels that do not decrease or that increase
What is the major sign that GTD disease is metastatic Describe the following stages of GTD: Stage I Stage II Stage III Stage IV Where does metastatic GTD spread
Disease that is limited to uterus Disease that extends outside uterus but stays within pelvis or vagina Disease with pulmonary metastases Disease spreads to other sites In order from most likely to least likely: Lung (80%)
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