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#16
06.03.2006, 21:49
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Цитата:
Cardinal features An ectopic pregnancy is one in which the fertilized ovum implants on any tissue other than the endometrial lining of the uterus It classically presents with abdominal or pelvic pain, amenorrhea, and abnormal vaginal bleeding; approx. 70% of patients exhibit all three symptoms together The presentation, however, may be very varied, from asymptomatic, in which the ectopic reabsorbs and remains undetected, through vague abdominal symptoms to an acute abdomen The diagnosis is not easy to make clinically, and a high index of suspicion must be maintained if diagnosis is to be made before rupture occurs. Clinical impression must be taken in combination with results from investigation The diagnosis should be considered in any woman of reproductive age who presents with abdominal pain, amenorrhea, or abnormal vaginal bleeding >40% of cases are still missed on initial consultation with a physician 50% of women give no history of any risk factors It is the most common cause of maternal death during the first trimester Causes Common causes Conditions that cause destruction of the normal anatomy of the tube or interfere with transport of the ovum to the uterine cavity are likely to be implicated in the cause of ectopic pregnancy: Pelvic inflammatory disease, particularly due to chlamydial infection. There is a 7-fold increase in the incidence of ectopic pregnancy in women with laparoscopically proven salpingitis Previous tubal surgery Infertility treatment: ovulation induction and in vitro fertilization are both associated with an increased risk of ectopic pregnancy Progesterone levels may affect fimbrial activity; there is reportedly an increase of incidence of ectopic pregnancy in patients who ovulate late and have a short luteal phase Endometriosis Incomplete tubal sterilization Intrauterine device (IUD): there is an increased risk of ectopic pregnancy in the context of failure of an IUD Fibroids (if they cause tubal obstruction) Rare causes Congenital abnormality Antineoplastic drugs Exposure to diethylstilbestrol (DES) in utero Salpingitis isthmica nodosa Contributory or predisposing factors Previous ectopic pregnancy History of infertility Multiple sexual partners Early age at first sexual intercourse Contraception: where an intrauterine device is used or sterilization has failed, there is a greater incidence of ectopic pregnancy Previous illegal abortion may predispose to an increased risk of ectopic pregnancy in subsequent pregnancies Epidemiology Further Reading Incidence and prevalence The incidence of ectopic pregnancy has increased 6-fold since 1970. This is generally ascribed to an increase in rates of sexually transmitted diseases, particularly chlamydia Death rates have generally declined during that time, probably due to improved diagnostic techniques. Reported rates vary depending on the method of expression of the data About 2-5% of clinical IVF pregnancies are ectopic Incidence In 1992 the incidence was 19.7 per 1000 pregnancies (live birth, legal abortion, ectopic). Prevalence 17,800 ectopic pregnancies were diagnosed in the US in 1970 108,000 were diagnosed in 1992 Frequency Currently, ectopic pregnancies account for around 2% of pregnancies in the US. Demographics Age The incidence of ectopic pregnancy increases with advancing age, although it may occur in any sexually active woman of reproductive age 40% of ectopic pregnancies occur in women aged 20-29 years Death from ectopic pregnancy is more common in younger women Race African-American women have a higher incidence of ectopic pregnancy and a 3-fold increase in death from ectopic pregnancy over Caucasian women A study in 1993 showed a 43% higher incidence in non-Caucasian women (e.g. African-American, hispanic women) Geography The US has been divided into four zones. The highest incidence has been reported in the south and lowest in the northeast, but the differences are not great and the ethnic mix is different in the four zones. Socioeconomic status There is an increased risk in socially disadvantaged women. Codes ICD-9 code 633.00 Abdominal pregnancy without intrauterine pregnancy 633.01 Abdominal pregnancy with intrauterine pregnancy 633.10 Tubal pregnancy without intrauterine pregnancy 633.11 Tubal pregnany with intrauterine pregnancy 633.80 Other ectopic pregnancy without intrauterine pregnancy 633.81 Other ectopic pregnancy with intrauterine pregnancy 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy 633.91 Unspecified ectopic pregnancy with intrauterine pregnancy 
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#17
06.03.2006, 21:51
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Clinical presentation
Further Reading Symptoms The classic triad of amenorrhea, pain, and abnormal vaginal bleeding is present in 70% of cases Amenorrhea occurs in 85% of cases, and the mean duration to onset of bleeding is 5.5 weeks; most ectopics present between 5 and 12 weeks of pregnancy Pain may be pelvic or abdominal; it may be present in only 30% of cases if the ectopic is unruptured and in 97-100% in cases of rupture Vaginal bleeding may initially be light or spotting but may become heavier; rarely, a decidual cast may be passed Syncope or dizziness may be present in 25% of patients Shoulder pain may occur in up to 20% of patients and is associated with rupture and hemoperitoneum Signs Only approx. 25% of patients will present with classic symptoms and cardiovascular instability; 20% of patients will present less dramatically, but will have prominent risk factors for ectopic pregnancy. The rest present subacutely with more subtle symptoms. This latter group poses the most difficult diagnostic problem. Shock with pallor, tachycardia, and hypotension: emergency presentation in <25% of patients Orthostatic hypotension may be present in approx. 10% of cases Abdominal tenderness is present in at least 90% of cases After rupture: signs of peritoneal irritation may be elicited, including guarding, rebound tenderness, and reduced bowel sounds Blood in the vagina may be seen in about 60% of cases Uterine enlargement is present in only 25% of cases; the cervix seldom appears gravid Adnexal mass may be palpated in 50% of cases Cul-de-sac fullness may be felt in 60% of cases Adnexal tenderness is present in 54% of cases Cervical excitation Associated disorders Pelvic inflammatory disease Infertility Endometriosis Sexually transmitted diseases, particularly chlamydial Differential diagnosis Spontaneous abortion Expulsion of all or part of the products of conception from the uterus. Dysfunctional uterine bleeding Dysfunctional uterine bleeding involves abnormal uterine bleeding in the absence of other detectable organic lesions. Acute appendicitis Acute appendicitis is acute inflammation of the vermiform appendix. Pelvic inflammatory disease Pelvic inflammatory disease is a broad term that covers a variety of upper genital tract infections: salpingitis, salpingo-oophoritis, tubo-ovarian inflammatory masses, pelvic peritonitis. Endometriosis Endometriosis involves heterotopic islands of endometrial tissue that can be found in many extrauterine locations: pelvic, vaginal, ovary, pelvic sidewalls, and uterosacral ligaments. Workup Diagnostic decision Rupture must be excluded The diagnosis of ectopic pregnancy is difficult to make clinically, especially in the majority in whom presentation is vague and subacute The diagnosis should be suspected in any woman of reproductive age. Amenorrhea, vaginal bleeding, and abdominal pain indicate an ectopic pregnancy until an intrauterine pregnancy is proven The most efficient way to exclude an ectopic pregnancy is to diagnose an intrauterine pregnancy. Diagnostic and surgical procedures can then be focused on women without a viable uterine pregnancy. (Bear in mind the extremely rare occurrence of heterotopic pregnancy.) Accurate diagnosis is desirable to avoid unecessary surgical procedures and interference with a normal pregnancy A high-sensitivity pregnancy test on urine should be performed in the office; the result will indicate the probability of a pregnancy-related disorder Measurement of serum hCG permits more accurate quantification, which is required to determine whether a pregnancy is normal or pathologic. It may be useful before 5 weeks' gestation when ultrasonography is unlikely to be of any assistance in diagnosis. The absolute level may also be useful in determining appropriate treatment options Transvaginal ultrasound can demonstrate an intrauterine pregnancy approx. 1 week earlier than the transabdominal approach; however, about 20-30% of ectopic pregnancies will have a normal ultrasound examination A combination of the results of transvaginal ultrasound and hCG measurement improves the accuracy of the diagnosis. This relies on the concept of a 'discriminatory zone,' which refers to the level of hCG above which the gestational sac of an intrauterine pregnancy should be detectable by ultrasound. The discriminatory level varies on the assay used and the quality of the ultrasound technique. Women with an hCG result above the discriminatory level and absence of an intrauterine gestational sac on ultrasound should be considered for laparoscopy to exclude ectopic pregnancy Serial hCG measurements are of greater value than single measurements in the prediction of early pregnancy problems, especially when the duration of the pregnancy is uncertain. A prolonged 'doubling time' is predictive of pathologic pregnancy Serum progesterone levels may be of value when the results of hCG and transvaginal ultrasound are inconclusive If all other tests are equivocal but the index of suspicion remains high, the patient should be referred for diagnostic laparoscopy The diagnosis can be confirmed by histologic evidence of trophoblast in the tube following salpingectomy or in material obtained at salpingostomy Guidelines The following guidelines are also available at the National Guidelines Clearinghouse : The American College of Radiology has produced the following guidelines: First trimester bleeding. American College of Radiology, Expert Panel on Women's Imaging. ACR Appropriateness Criteria 2005 Evaluation of left lower quadrant pain. American College of Radiology (ACR), Expert Panel on Gastrointestinal Imaging. American College of Radiology 2003 The American College of Emergency Physicians (ACEP) has produced: ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33 American College of Emergency Physicians (ACEP). Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000;36:406-15 The American College of Obstetricians and Gynecologists (ACOG) has produced: ACOG Practice Bulletin. Medical management of tubal pregnancy. ACOG Practice Bulletin no. 3. 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999;65:97-103. Considered current as of December 2004. Summary from the National Guideline Clearinghouse available here The Royal College of Obstetricians and Gynaecologists (RCOG) has produced: Clinical Green Top Guidelines. The management of tubal pregnancies. London: ACOG, 2004 The American Academy of Family Physicians has produced the following guidance information: Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14 Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8 Don't miss! Always do a pregnancy test in a woman who presents with abdominal pain and is of child-bearing age Rupture: there may be a sudden increase in pain, syncope, dizziness Heterotopic pregnancy: rare in spontaneous conceptions (1 in 30,000 quoted) but increasingly common, particularly in patients undergoing fertility treatments; may be a reason for continuing symptoms even after definitive treatment Bilateral and twin ectopics are rare, but are well reported in the literature Questions to ask Presenting condition When was the last normal menstrual period? What is the normal pattern, cycle length, volume of loss? Are cramps normally present? This will help establish the period of amenorrhea, but it is notoriously difficult information to elicit. Some ectopic pregnancies may present before the missed period When did this latest episode of bleeding start? How long has it lasted? How does it compare with a normal period? Has there been any passage of tissue or clot? Bleeding due to an ectopic may be quite light and described as spotting. Tissue and clot may be noticed in a spontaneous abortion What is the nature of the pain? Early in the course (4-6 weeks amenorrhea) there may be vague abdominal or pelvic pain. Later pain becomes sharp and may be sudden and severe. It is usually localized to the affected side, but may be on the opposite side if a leaking corpus luteum is also present. Shoulder pain may be present in the presence of rupture, but is not a specific or sensitive sign Have there been any fainting or dizzy spells? This may be associated with leaking or rupture of the ectopic Are there any pregnancy-associated symptoms? Vaginal discharge, urinary symptoms, weight change, nausea and vomiting, or breast tenderness may or may not be present. Ectopic pregnancy usually presents before these begin
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#18
06.03.2006, 21:53
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Contributory or predisposing factors
Is there a history of any predisposing factor? What contraceptive method is used? Pregnancy in the context of intrauterine device use or sterilization failure is more likely to be ectopic; 14% of patients give a history of intrauterine device use Has there been any previous pelvic surgery? Previous tubal surgery increases the risk of an ectopic pregnancy; pelvic surgery may result in adhesions Is there a history of infection or sexually transmitted disease? Previous pelvic inflammatory disease, chlamydia, or gonorrhea infection increase the risk of ectopic pregnancy. A high number of sexual partners has been found to be an independent risk factor for ectopic pregnancy Is there a history of infertility? Present in 15% of patients Is there a history of treatment with ovulation induction or in vitro fertilization? The risk of heterotopic pregnancy is also increased Is there a history of pelvic disease? For example, endometriosis, pelvic tumors, congenital abnormality Is there a history of genital trauma? Family history Is there a history of DES (diethylstilbestrol) exposure in utero? There is an increased risk of clear cell adenocarcinoma, which typically presents with noncyclical bright bleeding. Examination Is the patient well or unwell? Distress and pallor may indicate blood loss and severe pain. Fever is not usually a feature Is the patient shocked? Tachycardia and hypotension should alert to possible rupture of the ectopic. Orthostatic hypotension may be present in 10% of patients before shock actually becomes apparent Is there evidence of an intrauterine pregnancy? The abdomen may be distended, a mass felt, or a fetal heart auscultated. The most efficient way to exclude an ectopic pregnancy is to diagnose an intrauterine pregnancy; although a simultaneous intrauterine and ectopic pregnancy is possible, it is extremely rare Are there abdominal signs? Abdominal tenderness is present in about 90% of patients. Extreme tenderness, guarding, rigidity, and rebound tenderness are signs of peritoneal irritation and suggest a ruptured ectopic pregnancy Is there evidence of blood or tissue in the vagina? Large amounts of blood and tissue suggest a spontaneous abortion Is there adnexal tenderness, mass, cervical excitation, open or closed os? Adnexal tenderness or masses are only present in about half of patients Summary of tests High sensitivity pregnancy test: modern kits for urine testing are highly sensitive and specific and are easily kept in the office. A pregnancy test should be performed on all women of reproductive age with symptoms of amenorrhea, abdominal pain, and bleeding unless there is a compelling reason as to why pregnancy should not be suspected. A positive pregnancy test should result in the ordering of a transvaginal ultrasound Transvaginal ultrasound allows a diagnosis of pregnancy to be made earlier than transabdominal ultrasound. It may actually be normal in the presence of an ectopic pregnancy. Endovaginal color Doppler may be an adjunct to ultrasound in diagnosis Single serum measurement of human chorionic gonadotrophin (hCG): this may improve the diagnosis of ectopic in conjunction with transvaginal ultrasound Serial hCG measurement: may be used in both diagnosis and follow-up Hemoglobin: the patient may have a low hematocrit but usually does not Serum progesterone measurement is controversial but may be useful in certain situations Culdocentesis is the aspiration of nonclotting bloody fluid from the cul-de-sac. A positive result suggests a hemoperitoneum, but does not indicate the source of the blood or predict rupture of the ectopic. Although the sensitivity and specificity is low, it may be useful if ultrasound is not available and hemoperitoneum is suspected (normally performed by a specialist) Laparoscopy (performed by a specialist): patients in whom all other investigations are equivocal but there is a high index of suspicion will require referral to a specialist for diagnostic laparoscopy Tests Pregnancy test Ultrasonography (transabdominal or transvaginal) Serum human chorionic gonadotrophin (hCG) Serial serum hCG measurement Serum progesterone level Clinical pearls If you always think of ectopic pregnancy you will not miss the diagnosis If serum hCG is over 5-6000 milli-international units/mL and empty uterus on transvaginal ultrasound is high, then there is a likelihood of ectopic pregnancy It is not possible to predict rupture based on any individual feature of the history, individual risk factors, or hCG level Consider consult Diagnosis is not easy to make in the community or on clinical grounds alone, and any patient in whom the diagnosis cannot be excluded should be referred for further investigation and a definitive diagnosis Patients in whom ultrasonography measurements and single serum measurement of human chorionic gonadotrophin (hCG) are equivocal should be referred for laparoscopy Immediate urgent referral to an emergency department is needed if a ruptured ectopic is suspected Goals Prevention of serious morbidity or death Relief of symptoms Preservation of future fertility where required Patient education Immediate action Resuscitation of the shocked patient should begin immediately and vigorously Urgent surgery is indicated in the presence of rupture and potentially catastrophic bleeding Therapeutic options Summary of therapies In many circumstances the clinical condition will dictate the necessary action but, where there is no obvious clear choice, the patient's wishes may need to be taken into account Surgical treatment is the traditional standard and may be carried out either by laparotomy or laparoscopy A salpingectomy (removal of the affected tube) or a salpingostomy (evacuaton of the ectopic from the tube) may be carried out by either approach Surgery is the preferred treatment for patients with: hypotension/shock, prolonged pain (24h plus), evidence of rupture, quantitative hCG >10,000 mIU/mL, or larger gestation sacs (>3.5cm) on ultrasound Medical treatment is recently more widely used, and involves the administration of methotrexate Expectant management is not recommended and should only be practiced under specialist supervision. It is possible that some ectopics will resolve spontaneously. The initial titer of hCG and the trend on serial monitoring are both predictors of sucess. The higher the initial concentration, the more likely it is that expectant treatment will fail. If the initial concentration is <1000 milli-international units/mL, expectant management can be successful in 88% of cases Guidelines The following guidelines are also available at the National Guidelines Clearinghouse : The American College of Emergency Physicians (ACEP) has produced: ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33 American College of Emergency Physicians (ACEP). Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000;36:406-15 The American College of Obstetricians and Gynecologists (ACOG) has produced: ACOG Practice Bulletin. Medical management of tubal pregnancy. ACOG Practice Bulletin no. 3. 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999;65:97-103. Considered current as of December 2004. Summary from the National Guideline Clearinghouse available here ACOG Practice Bulletin. Prevention of Rh D alloimmunization. ACOG practice bulletin; no. 4. American College of Obstetricians and Gynecologists 1999. Summary from the National Guideline Clearinghouse available here The Royal College of Obstetricians and Gynaecologists (RCOG) has produced: Clinical Green Top Guidelines. The management of tubal pregnancies. London: ACOG, 2004 The United States Preventive Services Task Force has produced: Screening for Rh(D) incompatibility: recommendation statement. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2004 The American Academy of Family Physicians has produced the following guidance information: Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14 Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8 Efficacy of therapies Salpingectomy performed during laparotomy produces success rates of 100% A persistent ectopic requiring further treatment may occur in 8% of cases following salpingostomy. The need for further treatment may be virtually eliminated by the administration of methotrexate at the time of operation Methotrexate is 95% effective in carefully selected cases when used as primary treatment Medications and other therapies Laparotomy or laparoscopy Salpingectomy Salpingostomy Methotrexate Summary of evidence Evidence References
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#19
06.03.2006, 21:53
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There is evidence that both open and laparoscopic surgical intervention is effective in the management of ectopic pregnancy.
A systematic review found that open salpingostomy is significantly more successful than laparoscopic salpingostomy in eliminating ectopic pregnancy [1] Level A This review also found that laparoscopy and open surgery have similar long-term tubal patency rates and subsequent intrauterine pregnancy rates, but laparoscopy has a tendency to reduce subsequent ectopic rates, is cheaper, and reduces operating, hospital stay and convalescent time [1] Level A There is evidence that, in patients with ectopic pregnancy, surgical intervention is more effective than medical management with methotrexate. A systematic review has found that laparoscopic salpingostomy was significantly more successful than single-dose methotrexate in the treatment of small unruptured ectopic pregnancy [1] Level A This review also found that systemic methotrexate, given as multiple intramuscular injections, is as effective as laparoscopic salpingostomy in eliminating ectopic pregnancy, but is associated with a decreased quality of health [1] Level A The role of methotexate in the management of ectopic pregnancy in selected patients is supported by data from observational studies and endorsed by expert opinion. Observational studies have found that single-dose methotrexate, with a second dose dependant upon lack of response (as defined by serum gonadotrophin hormone levels) is successful in approx. 90% of cases of uncomplicated ectopic pregnancy [2,3] Level B The American College of Obstetricians and Gynecologists recommends that single-dose methotrexate (50mg/m2) may be used for the treatment of ectopic pregnancy when serum hCG is between 6-15, 000 mIU/mL [4] Level C There is a lack of randomized trials that evaluate the use of anti-D immunoglobulin in patients with first trimester pregnancy loss and ectopic pregnancy. However, its use is supported by limited data and endorsed by expert opinion. A systematic review of randomized trials in Rhesus-negative women concluded that administration of anti-D immunoblobulin at 24 weeks' and 34 weeks' gestation during the first pregnancy reduces the risk of Rhesus-D antibody formation and alloimunisation from 1% to 0.2% [5] Level A Another systematic review found that although the evidence from randomized trials is sparse, its theoretical value is strong, and the authors conclude that there is little risk associated with its use [6] Level A Evidence-based recommendations from the American College of Obstetricians and Gynecologists state that all unsensitized Rh-negative pregnant women should be given Rh immune globulin within 72 hours of an abortion [7] Level C This treatment rationale is also endorsed by the American College of Emergency Physicians [8] Level C Clinical pearls The earlier the diagnosis is made, the greater the chance of salvaging the tube and preserving future fertility. Management in special circumstances A patient with a history of infertility may wish to preserve the tube at all costs and treatment will be directed toward conservative techniques if at all possible Patients being treated medically or followed after conservative surgery still have a small risk of treatment failure and persistent ectopic. Such a patient who has increased pain, dizziness, or syncope requires urgent referral Coexisting disease A subfertile patient may wish to avoid salpingectomy. Special patient groups Younger patients and those with no previous children are more likely to want to preserve fertility IVF patients Patient satisfaction/lifestyle priorities Laparoscopic surgery is associated with shorter hospital admissions, lower requirement for analgesia postoperatively, less blood loss, and a shorter recovery time It may be more convenient for patients with young children or other dependants to be managed medically rather than via a procedure requiring hospital admission There is a need for rigorous follow-up after both conservative surgical procedures and medical management and the patient must have the ability and desire to comply Some patients may prefer definitive treatment with a salpingectomy with its more instant guarantee of cure and lesser need for follow-up Patient and caregiver issues Questions patients ask Patients may wish to discuss their prospects of future pregnancy relating to the different treatment procedures Patients who believe that life begins with conception may prefer treatment with salpingectomy. The Catholic church holds the view that in this case death of the fetus is secondary to the procedure and not a primary act Health-seeking behavior Has the patient waited too long to seek care? A patient with a previous ectopic or risk factor should be counseled to seek care for early assessment in subsequent pregnancies Has the patient visited ER or other physician? Bear in mind that 40-50% of women with an ectopic pregnancy may be missed on their initial presentation to a physician Follow-up Plan for review Following treatment with either salpingostomy or methotrexate, weekly hCG levels are required until titers are below 5 milli-international units/mL. Information for patient or caregiver Patients undergoing medical management should be made aware of the early warning symptoms of rupture (increased pain, dizziness, syncope) and advised to report immediately to an emergency department if they occur. Ask for advice Question 1 Why are these patients at increased risk for infertility? Answer 1 The most likely reason is tubal dysfunction or adhesion formation following surgery. It has been estimated that about 20% of women who have an ectopic will become infertile. Question 2 How does one decide which method of treatment to use? Answer 2 This depends on the wishes of the patient regarding future fertility. If the patient wants to preserve fertility, then conservation of the affected tube is preferred over resection, or avoid surgery and treat medically if a suitable candidate. Whether laparoscopy or laparotomy is performed depends on the surgical skill of physician. Question 3 Is there an increased risk of ectopic pregnancy in women with endometriosis? Answer 3 No increase in risk has been associated with endometrosis unless it has caused tubal damage or adhesions from previous surgery. Question 4 What is the most common site for an ectopic pregancy? Answer 4 The fallopian tube accounts for 98% of ectopics. The most common are ampullary (93%), isthmic (4%), and cornual (2%). Cornual pregnancies can be very difficult to diagnose because you can get a report from a radiologist of IUP on ultrasound. So if you suspect ectopic, follow patient with serial hCGs. Consider consult Immediate referral to an emergency department is mandatory if the patient is hemodynamically unstable All patients with a diagnosis of ectopic pregnancy will need referral for treatment to an obstetrician and gynecologist Expectant management may be an option in very limited circumstances Prognosis Further Reading The future reproductive potential of patients who have had an ectopic pregnancy is poor. Only 50% of women have a subsequent live birth and this is broadly similar for all modes of treatment. Clinical pearls After salpingostomy refer the patient for hysterosalpingography in 3 months to check for tubal patency Don't forget to give RhoGAM to Rh-negative women Progression of disease Therapeutic failure Therapeutic failure will result in persistence of the ectopic pregnancy. After conservative procedures this is quoted as being from 5-20%. This may be demonstrated by hCG levels that either do not fall or start to rise again during the follow-up period. A second laparoscopy may be required, but the decision should be based on symptoms as well as hCG changes In rare circumstances (but well described in the literature) the occurrence of bilateral ectopics may present as therapeutic failure Recurrence Recurrence of an ectopic pregnancy seems to be similar for all modes of treatment and is variously quoted as up to 26%, with averages around 6-12%. Clinical complications Further Reading Persistent ectopic Recurrent ectopic Infertility, loss of reproductive organs after complicated surgery Hemorrhage resulting in the need for transfusion, disseminated intravascular coagulation, and the attendant risks of those conditions Death: ruptured ectopic pregnancy is the most common cause of maternal death in the first trimester Consider consult Refer if follow-up hCG levels do not fall or start to rise again Refer if symptoms do not abate completely
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#20
06.03.2006, 21:54
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Primary prevention
Further Reading Modifiable risk factors Tobacco Patients should be advised to stop smoking. This is a proven risk factor. Sexual behavior Patients should be encouraged to reduce the number of sexual partners and to practice safe sex to avoid the risk of sexually transmitted diseases A reliable method of contraception should be used Secondary prevention Recurrence of an ectopic pregnancy in patients who have previously been diagnosed with an ectopic is variously reported in different studies. A meta-analysis of 20 studies gave a combined odds ratio of recurrence of 8.3, and a prospective study gave a risk of recurrence of 12%. Preventive measures to reduce the risk of recurrence are few, and measures to target early identification should be employed. Advise adequate contraception, avoid use of the intrauterine device Fertility treatment including ovulation induction should be carried out under expert supervision Raise patient awareness of the likelihood of recurrence and advise early attendance for assessment in the event of symptoms 'that feel the same as before' or when pregnancy is suspected Screening Further Reading While there may not be a case for population screening for chlamydia, there is certainly a good case for targeted screening of women who are: Sexually active at <25 years of age With a new sexual partner With multiple partners in the previous year Using nonbarrier methods of contraception With symptoms of chlamydial infection: cervical friability, mucopurulent discharge, or intermenstrual bleeding Guidelines The United States Preventive Services Task Force has produced: Berg AO. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med 2001;20(3 Suppl):90-4. Also available at the National Guideline Clearinghouse References Evidence references ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33 ACOG Practice Bulletin. Prevention of Rh D alloimmunization. ACOG practice bulletin; no. 4. American College of Obstetricians and Gynecologists 1999 ACOG Practice Bulletin. Medical management of tubal pregnancy. ACOG Practice Bulletin no. 3. 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999;65:97-103 Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens. Obstet Gynecol 2003;101:778-84. Reviewed in: Methotrexate for ectopic pregnancy. Bandolier J 2003;112-3 and in DARE Document 297354. York, UK: Centre for Reviews and Dissemination Crowther CA, Middleton P. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. The Cochrane Database of Systematic Reviews 1999, Issue 2 (Cochrane Review) Hajenius PJ, Mol BWJ, Bossuyt PMM, et al. Interventions for tubal ectopic pregnancy. The Cochrane Database of Systemic Reviews 2000, Issue 1 (Cochrane Review) Jabara S, Barnhart KT. Is Rh immune globulin needed in early first-trimester abortion? A review. Am J Obstet Gynecol 2003;188:623-7 Lipscomb GH, McCord ML, Stovall TG, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med 1999:341:1974-8 Guidelines The following guidelines are also available at the National Guidelines Clearinghouse : The American College of Radiology has produced the following guidelines: First trimester bleeding. American College of Radiology, Expert Panel on Women's Imaging. ACR Appropriateness Criteria 2005 Evaluation of left lower quadrant pain. American College of Radiology (ACR), Expert Panel on Gastrointestinal Imaging. American College of Radiology 2003 The American College of Emergency Physicians (ACEP) has produced: ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med 2003;41:123-33 American College of Emergency Physicians (ACEP). Clinical policy: critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000;36:406-15 The American College of Obstetricians and Gynecologists (ACOG) has produced: ACOG Practice Bulletin. Medical management of tubal pregnancy. ACOG Practice Bulletin no. 3. 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999;65:97-103. Considered current as of December 2004. Summary from the National Guideline Clearinghouse available here ACOG Practice Bulletin. Prevention of Rh D alloimmunization. ACOG practice bulletin; no. 4. American College of Obstetricians and Gynecologists 1999. Summary from the National Guideline Clearinghouse available here The Royal College of Obstetricians and Gynaecologists (RCOG) has produced: Clinical Green Top Guidelines. The management of tubal pregnancies. London: ACOG, 2004 The United States Preventive Services Task Force has produced: Screening for Rh(D) incompatibility: recommendation statement. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2004 Berg AO. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med 2001;20(3 Suppl):90-4. The American Academy of Family Physicians has produced the following guidance information: Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician 2005;72:1707-14 Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8 Further reading Farquhar CM. Ectopic pregnancy. Lancet 2005;366:583-91 Lipscomb GH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000:343;1325-9 Tay JI, Moore J, Walker JJ. Ectopic pregnancy. BMJ 2000;320:916-9 Barnhart K, Esposito M, Coutifaris C. An update on the medical treatment of ectopic pregnancy. Obstet Gynecol Clin North Am 2000;27:653-67 Anderson FW, Hogan JG, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet Gynecol 2004;103:1218-23 Carr RJ, Evans P. Update in maternity care: ectopic pregnancy. Prim Care 2000:27:169-83
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#21
06.03.2006, 21:56
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[Ссылки доступны только зарегистрированным пользователям ]
American College of Obstetricians and Gynecologists (ACOG). Medical management of tubal pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1998 Dec. 7 p. (ACOG practice bulletin; no. 3)
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Линейный вид
