Secrets 50J

Avoid invasive procedure
Avoid anesthesia (usually)
High success rate (~95%)

Need 2+ visits
May take days to wks to complete
Use confined to early pregnancy
Requires f/u to ensure is complete
Generally multi-step process

Can use sedation is desires
Usually needs only 1 visit
Finished in a predictable time frame
Use in early or later pregnancy
High success rate (~99%)
Single step process

Invasive procedure

Suction curettage w/ smaller (6mm) canula and manual vacuum aspiration
Afterward, try to ID villi (powder puff pattern when floated in water)
If can't see the villi, follow w/ serial β-hCG to r/o ectopic & confirm termination

Vacuum aspiration w/ electric vacuum pump
Use suction cannulas according to GA
Inspect tissue for villi, sac, fetal parts if >10wks

Use lamicel or laminaria to soften and dilate the cervix
Evacuate uterus
Suction a/o sharp curettage
ID fetal parts post procedure to ensure completeness

>13wks

Mifepristone (RU-486) - usually in combo w/ misoprostol
Methotrexate - also usually in combo w/ misoprostol

Up to 49d

Progesterone-R antagonist

Inhibits syncytialization of the cytotrophoblast & therefore prevents implantation

With MTX, 15-20% of pts may have to wait up to 4wks for abortion to occur

1) Incomplete abortion requiring surgical evacuation (~5%)
2) Hemorrhage requiring emergency d&c (<1%)
3) Post abortal endometritis (0.09-0.5%)

Bleeding & pain
Nausea (12-47%)
Vomiting (9-45%)
Diarrhea (7-67%)
Warmth or chills (14-89%)
H/a (12-27%)
Dizziness (14-37%)
Fatigue

1) Uterine perforation (<1%)
2) Hemorrhage (<1%)
3) Post abortal endometritis (0.4-4.7%)
4) Incomplete abortion (~1%)

Early and mid-2nd-T gestations
Allow abortion w/o fetal dismemberment

Intra-amniotic instillation of:
1) hypertonic saline
2) urea
3) PGF2a

Or, extra-aminotic admin of PGE2 via vagina
Or, high-dose oxytocin IV

Hyperosmolar coma
HyperNa
DIC

D&E or vaginal prostaglandins (safer up to 20wks)

Mortality was 39% in 1972
6% in 1974

Today overall risk in <1:100k procedures

~1.3million

Any pregnancy that develops at any site other than the endometrium

1) ranges from 1:64 to 1:241
Averages ~20/1000
2) Has been 4fold increase since 1985 2/2 increasing salpingitis and better ABX, so tube is now patent but has luminal dmg.

Ectopic pregnancy

Is 2nd MCC of death in pregnancy overall - 10-15% of maternal deaths

Major: salpingitis
Others: infection (esp w/ CT), DES exposure, prior tubal surgery, smoking during time of conception
~3% is 2/2 failure of tubal sterilization method
Also, chromosomal and structural abnormalities in fetus may predispose to ectopic

97.7% occur in fallopian tube (ampulla >isthmus >fimbriae)
1.4% are abdominal
<1% are ovarian or cervical

1) Tube + fimbria ovarica must be intact
2) Gestational sac must occupy normal ovarian position
3) sac must be connected to uterus via utero-ovarian ligament
4) Ovarian tissue must be IDed by histo in wall of gestational sac.

1:30,000 (traditional)

1:4000-15,000 (more likely, since IVF has increased the risk to up to 3% of successful transfers)

TRUE

OCPs & diaphragm = 1%
IUD = 5%
Progestasert IUD = 15%

btw 7-15%

1) H/o tubal surgery
2) H/o PID
3) Previous ectopic
4) IUD use
5) Progestin-only OCPs
6) DES exposure
7) Endometriosis
8) Cigarette smoking

1) Threatened or incomplete AB
2) gestational trophoblastic disease
3) Ruptured corpus luteal cyst
4) Salpingitis
5) Appy
6) DUB
7) Ovarian torsion
8) Degenerating fibroid
9) Endometriosis

Increased morbidity (substantial)

>90% of pts have abdominal pain
Only 35% report completely missing a period (though usually have some abnormality)
May have abnormal bleeding at time of presentation

Referred from diaphragmatic irritation 2/2 hemoperitoneum
Up to 25% of pts report this

Abdominal tenderness (>90%)
Palpable pelvic mass ~50%
Normal uterine size in 70%
Usually afebrile
Orthostasis only in massive hemoperitoneum

During 1st 6-7wks, hCG doubles q48H
Only 17% of ectopics meet criteria for normal doubling times
Follow titers is helpful in ruling out ectopic pregnancu

When can see fetal cardiac activity in either tube or uterus

Less frequently needed now, but useful if pt has +UPT and fluid in cul-de-sac and NO definitive intrauterine sac
Or if titers and US aren't available

B/c is clotted blood that's been lysed already
Its hemocrit should be >15% to be significant

Abdominal pain
Abnormal vaginal bleeding

98% of viable pregnancies progesterone is >10ng/mL
98% of NON-viable pregnancies, progesterone is <20ng/mL
So, one level <15ng/mL suggests non-viable, but doesn't distinguish btw pending SAB and ectopic

Short answer: Role is limited!!

Allows visualization of the tube

Note: false negative rate is ~4%, may be higher if done early in pregnancy

Hospitalize pt for observation w/ surgery only for hemorrhage -> 57% of ectopics spontaneously resolve

BUT, 60% of pts are hospitalized for >4wks, so not very practical!

1) Traditional: Laparotomy w/ partial salpingectomy
2) Newer: Linear salpingostomy (laparoscopy)

Note: 10% risk of persistent trophoblast, so follow until hCG is undetectable.

MC dose: 50mg/m2 IM x1

Can give multi-dose or single dose
Has been reported to be successful in treating interstitial, abdominal, and cervical pregnancies

Median success rate: 85%
80% tubal patency afterward

Inhibits folic acid synthesis -> blocks DNA synthesis & cell multiplication

Stomatitis
Dermatits
Pleuritis
Altered liver fxn
~60% of pts report increased abdominal pain w/ 1st few days

Known MTX sensitivity
Breast feeding
Immunodeficiency
Chronic liver/lung disease
Blood dyscrasias
Embryonic ectopic cardiac activity
Some: hCG >10,000 or sac >35mm

Actinomycin-D (especially for more advanced)
KCl into fetal heart in advanced
Possibly RU-486 + MTX (~97% success)