The majority of ectopic pregnancies occur in the fallopian tube 96 percent, but other possible sites include cervical, interstitial also referred to as cornual, a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus, hysterotomy scar eg, in. Medical management as with all types of ectopic pregnancy, medical management of abdominal pregnancy has been reported. Diagnosis and management of ectopic pregnancy bmj sexual. Suspect ectopic pregnancy in a client whose history includes a missed menstrual period, spotting, or bleeding pelvic or shoulder pain, use of intrauterine device, pelvic infections, tubal surgery, or previous ectopic pregnancy. Women of reproductive age presenting acutely with gastrointestinal symptoms, particularly diarrhoea, as well as those presenting with abdominal pain andor vaginal bleeding should have a urinary hcg test. Approved by job title date gynaecology clinical governance chair, gynaecology clinical governance 15th february 2019. Salpingectomy is the common surgical method for the.
Failure of the hcg level to decrease by at least 15% from day 4 to day 7 after methotrexate administration is considered treatment failure requiring therapy with either. See table 1 for a summary of medical management protocols. A healthy 29yearold woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain in her left lower quadrant for the past 3 days. The most common site of ectopic pregnancy is the fallopian tube.
This is a policy for maternity services with respect to the management of early pregnancy complications in early pregnancy assessment service s epas. Diagnosis and management of ectopic pregnancy greentop. In current practice, in developed countries, diagnosis. Medical management has become increasingly popular in the treatment of ectopic pregnancy. Laparoscopic management of ectopic pregnancy at birat. Medical management of ectopic pregnancy protocol cg623 approval and authorisation. If the diagnosis of ectopic pregnancy can be made earlier noninvasively, medical treatment with systemic intramuscular methotrexate mtx aimed at reducing. Given its convenience, for many it is used as a firstline treatment, however, this. The diagnosis and management of pregnancy of unknown location will not be covered. Currently, women may also be offered medical management, with the use of methotrexate an antifolate agent if they are haemodynamically stable with confirmed diagnosis of ectopic pregnancy on ultrasound scan, no significant pelvic pain, no hemoperitoneum, no fetal heart in the ectopic pregnancy, size of ectopic pregnancy 10 iul 34. It is usually terminated by a rupture in the first trimester and because of the increased vascularization of the ovarian tissue it leads to internal hemorrhage and hypovolemic shock status. Serum progesterone level 25 ngmml is suggestive of normal intrauterine pregnancy.
The chances of having a successful pregnancy after an ectopic pregnancy may be reduced, but this will depend on why the pregnancy was ectopic and your medical history. June 2008 volume 111 issue 6 p 14791485 acog publications. In clinically stable women in whom a nonruptured ectopic pregnancy has been diagnosed, laparoscopic surgery or. Your doctor has suggested that it is appropriate to treat your ectopic pregnancy with a drug called methotrexate. As a result, medical therapy with systemic methotrexate has become the firstline treatment, with surgery reserved. An hcg level that remains high could indicate that the ectopic tissue was not entirely removed, which would require surgery or medical management with methotrexate. An ectopic pregnancy occurs when a fertilised ovum implants outside the normal uterine cavity. An ectopic pregnancy is a pregnancy outside of the uterine cavity. If ectopic pregnancy has been diagnosed, the patient is deemed clinically stable, and the affected fallopian tube has not ruptured, treatment options include medical management with intramuscular.
The incidence of ectopic pregnancy showed a steady increase with the increase in maternal age at conception from 1. Medical management of an ectopic pregnancy is with im methotrexate. The use of methotrexate to treat ectopic pregnancy was first cited in 1982. Medical management with methotrexate can be considered for cervical ectopics.
It is an antifolate cytotoxic agent that disrupts the folate dependent cell division of the developing fetus. After an ectopic pregnancy has been confirmed, treatment options include medical, surgical, or expectant management. In the united kingdom nearly 12 000 ectopic pregnancies are diagnosed each year, which gives a prevalence of 1. If an ectopic pregnancy is diagnosed early but active monitoring isnt suitable, treatment with a medicine called methotrexate may be recommended. Since ectopic pregnancy is extensive increasing trouble in the women of reproductive age. The development of algorithms for diagnosis and medical management using mtx has. Ectopic pregnancy diagnosis and management in gynaecology. Ectopic pregnancy is a lifethreatening obstetric emergency and a leading cause of maternal mortality and morbidity around the globe. You wont need to stay in hospital after treatment, but regular blood tests will be carried out. The etiology of ep concentrated mainly on factor causes delayed transport of the fertilized ovum through the fallopian tube favors implantation in tubal mucosa, thus giving rise to ep.
A decrease in beta hcg by more than 15% between day 4 and day 7 after treatment shows successful medical treatment. Medical management of ectopic pregnancy clinical practice. Pdf medical management of ectopic pregnancy a case history. Methotrexate can be considered in those women with a confirmed, or high clinical suspicion of, ectopic pregnancy who are hemodynamically stable with an unruptured mass. Medical management of ectopic pregnancy sciencedirect. Hcg level is monitored regularly to ensure the level is declining by 15% in day 45. New 2016 c women receiving methotrexate for the management of tubal ectopic pregnancy can be advised that there is. The estimated prevalence of ectopic pregnancy is 12% worldwide. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. Medical management of ectopic pregnancy if you have been diagnosed with an ectopic pregnancy we understand this may be a very distressing time and we are sorry for your loss. Medical management of an ovarian ectopic pregnancy.
Although ectopic pregnancy remains a leading cause of lifethreatening firsttrimester morbidity, accounting for about 9% of maternal deaths annually, 1 we now are able to diagnose and treat most cases well before rupture occursin some cases, as early as 5 weeks gestation. Surgical management of ectopic pregnancy natural progress of t ubal ectopic pregnancy. The aetiology of ectopic pregnancy remains uncertain although a number of risk factors have been identified. This guideline replaces the management of tubal pregnancy, which. Medical treatment of non complicated ectopic pregnancy is an alternative for the management of this pathology. Medical management of ectopic pregnancy request pdf. This document has been withdrawn or is no longer available. Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. Hcg levels and successful medical management of an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants itself outside of the uterus. When administering methotrexate therapy, it is essential to remain aware of the risks and side effects of medical management. However, of those who underwent or elected surgical management, only 3% had a ruptured ectopic pregnancy in the course of the study. This guideline will cover the following ectopic pregnancies.
Diagnosis and management of ectopic pregnancya basic view. Clinical practice guideline the diagnosis and management of ectopic pregnancy 3 key recommendations 1. An ectopic pregnancy ep falls within the area of the gynecological emergency andor reproductive management of women, which is the implantation of fertilized ovum outside the endometrial cavity. Agents used to treat these ectopic pregnancies include methotrexate systemic and local,4,31 local instillation of potassium chloride,32 hyperosmolar glucose, prostaglandins, danazol, etoposide and mifepristone. Diagnosis and management of ectopic pregnancy 2016 bjog. Maternity management of early pregnancy complications. For patients who are medically unstable or experiencing lifethreatening. Rupture of ectopic pregnancy during methotrexate treatment ranges from 714%.
There was also a secondary finding of a corpus luteum cyst. Diagnosis and management of ectopic pregnancy aafp. To date there have been no wellpowered comparative studies between the two dose protocol and the single dose protocol, or the multidose protocol. Medical management of ectopic pregnancy with methotrexate, an antimetabolite of folic acid, is an important alternative to surgical treatment, as it. The rate of increase in hcg is one predictor of rupture. Draft clinical practice guideline the diagnosis and management of ectopic pregnancy 3 key recommendations. Diagnosis and management of ectopic pregnancy the bmj. There are different criteria for its use, and published success rates are heterogeneous. Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1. Other indications for surgery include no desire for or an inability to comply with medical treatment, contraindication to methotrexate, and failure of medical treat. Therefore immediate effective treatment and management are required to save women. To outline the medical management of tubal ectopic pregnancy.
The routine use of an ultrasound scan for women,who present with early pregnancy symptoms like pain or bleeding facilitates,an early diagnosis of ectopic pregnancy and medical treatment can be administered in most cases. Foster, dphil, md, am amanda dennis, mbe fiona smith, mph acknowledgements this research was conducted by ibis reproductive health for the national womens law center. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. Theyre also called tubal pregnancies because most of them happen in the fallopian tubes. Its given as a single injection into your buttocks. The objective of management in ectopic pregnancy is to make an early diagnosis, treat, prevent complications, and consequently to improve.
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