Pregnant and Bleeding in the I have no disclosures. First Trimester - - PDF document

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Pregnant and Bleeding in the First Trimester

Jody Steinauer, MD, MAS

D e p t . O b / G y n & R e p r o d u c t iv e S c ie n c e s

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Disclosures- July 3, 2018

I have no disclosures.

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Objectives

• 1. Review the workup of bleeding in the first trimester
• 2. Apply evidence-based principles to ectopic pregnancy (EP)

and early pregnancy loss (EPL) diagnoses

• 3. Apply evidence-based counseling and treatment for EPL and

EP

!

Patient Case: Presentation

• Maya is a 26 yo G1P0 presenting to the emergency room
• How do we care for Maya?

“I’m 2 months pregnant and I’m bleeding and

• cramping. Am I going to lose the baby?”

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Patient Case: H&P

• Sure LMP was 9 weeks ago
• Positive UPT 2 weeks ago
• Desired pregnancy
• First prenatal care visit scheduled for next week
• Bleeding is like a “light period” for the past 3 days
• No risk factors for ectopic pregnancy
• On exam closed cervical os
• Rh-negative

What can we tell Maya right now?

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Symptomatic Early Pregnancy Evaluation

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Symptomatic Early Pregnancy

• Ectopic pregnancy must be ruled out, but we must not

diagnose a desired IUP as abnormal – There are new guidelines for the hCG discriminatory zone

• Management is a preference-sensitive decision

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Symptomatic Early Pregnancy: Presentation

• Urgent or emergency care visit

– Vaginal bleeding – Abdominal or pelvic pain or cramping – Passage of pregnancy tissue from the vagina – Loss of pregnancy-related symptoms – Hemodynamic instability

• Incidental clinical finding

– Bimanual exam inconsistent with LMP – Ultrasound suggestive of abnormal pregnancy

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Bleeding in Early Pregnancy

• Keep the patient informed.

– Provide reassurance that not all vaginal bleeding & cramping = an abnormality, but avoid guarantees that “everything will be all right” – Assure that you are available

• What does the bleeding mean?

– Up to 20% chance of ectopic pregnancy – 50% ongoing pregnancy with closed cervical os – 85% ongoing pregnancy with viable IUP on sono – 30% of normal pregnancies have vaginal bleeding

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Evaluation

• History

– Risk factors for ectopic pregnancy

• Physical exam

– Vital signs – Abdominal and pelvic exam

• Ultrasound

– Transvaginal often necessary

• Lab

– Rh factor – Hemoglobin or Hematocrit – β-hCG when indicated Is the pregnancy desired?

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Ectopic Pregnancy

• 1-2% of all pregnancies
• Up to 20% of symptomatic pregnancies
• ½ of ectopic patients have no risk factors
• Mortality has dramatically declined: 0.5/100,000

– 6% of pregnancy-related deaths – 21 deaths per year in US

• Early diagnosis important
• Concern about management errors

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Early Pregnancy Loss (EPL)

• 15-20% of clinically

recognized pregnancies

• 1 in 4 women will

experience EPL

• Includes all non-viable

pregnancies in first trimester = miscarriage

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Pregnancy of Unknown Location

• When the pregnancy test is positive, but no signs of

intrauterine or extrauterine pregnancy on u/s – We try to follow these women until a diagnosis is made – We have to weigh risk of ectopic pregnancy (EP) – Sometimes there is never a final diagnosis as both EPL and EP may resolve spontaneously

• More commonly encountered in symptomatic early

pregnancy, but can also be encountered in asymptomatic women, especially when u/s early

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Positive pregnancy test, vaginal bleeding and/or abdominal pain 61% Ongoing IUP 28% Spontaneous Abortion 9% Ectopic Pregnancy Dxupon presentation (80% ) 77% O ngoing IU P 16% Spontaneous Abortion 6% Ectopic Pregnancy 49%

• f all w
• m

en w ith Ectopic Dxat presentation Dxw ith additional testing (20% ) 11% O ngoing IU P 77% Spontaneous Abortion 17% Ectopic Pregnancy 51%

• f all w
• m

en w ith Ectopic Dxafter outpatient follow

• up

Barnhart 2004 Obstet Gynecol

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Simplified Workup of Bleeding &/or Pain

1. Where is the pregnancy? à U/S (same day, if possible) 2. If the pregnancy undesired? à uterine aspiration 3. If desired and we can’t tell where it is: Is it normal or abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al – Serial beta HCGs:

• If Bhcgdrops > 50% in 48 hours = Abnorm

al

• If Bhcgrises > 50%

in 48 hours = M

• st likely norm

al (can be EP) – Continue to follow and repeat u/s

• If betw

een = M

• st likely abnorm

al (still can be norm al) – Continue to follow and repeat u/s

• 4. Once pregnancy clearly abnormal, if undesired or if

patient desires definitive dx à uterine aspiration

IU P=Intrauterine pregnancy

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β-hCG Utility in Symptomatic Early Pregnancy Diagnosis

• β-hCG m edian serum concentration:

– 4 weeks: 100 mIU/ml (5-450) – 10 weeks: 60,000 (5,000 – 150,000)

Discriminatory Level

• Serum β-hCG at which a norm al intrauterine

pregnancy should be visualized on ultrasound – If >2000 nl IUP unlikely but possible à new values

• Once above, lim ited role for “following betas”

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Discriminatory & Threshold level

• 366 ♀ with VB/painà nl IUP

Old value of 2000= 91% prob.

• f seeing GS in viable IUP

99% Predicted Probability of Detection Discriminatory Threshold Gestational sac Yolk sac Fetal pole 3510 17,716 47,685 390 1094 1394 Highest seen in the study with no sac: 2,300

Connolly, Obstet Gynecol, 2013.

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• HCG 2000 - 3000

– Non-viable pregnancy most likely, 2X ectopic – Ectopic is 19 x more likely than viable pregnancy – For each viable pregnancy:

• 19 ectopic pregnancies
• 38 nonviable pregnancies

– 2% chance of viable pregnancy

• HCG > 3000

– Ectopic 70 x more likely than viable pregnancy 0.5% chance viable IUP In women with desired pregnancy consider beta hcg cut-off of >= 3000.

Society of Radiologists in Ultrasound: No Gestational Sac

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Balance of Diagnostic Tests

• Maximize sensitivity at the cost of diagnosing some

IUPs as Ectopic Pregnancies – Error – interrupting desired IUP

• Maximize specificity at the cost of diagnosing some

EPs as IUPs – Error – delay diagnosis resulting in rupture

• Use cut-off of 3,000 v. repeat beta hcg or u/s

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Simplified Workup of Bleeding &/or Pain

1. Where is the pregnancy? à U/S (same day) 2. If the pregnancy undesired? à uterine aspiration 3. If desired and we can’t tell where it is: Is it normal or abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al – Serial beta HCGs:

• If Bhcgdrops > 50% in 48 hours = Abnorm

al

• If Bhcgrises > 50%

in 48 hours = M

• st likely norm

al (can be EP) – Continue to follow and repeat u/s

• If betw

een = M

• st likely abnorm

al (still can be norm al) – Continue to follow and repeat u/s

• 4. Once pregnancy clearly abnormal, if undesired or if

patient desires definitive dx à uterine aspiration

IU P=Intrauterine pregnancy

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β HCG trends in normal IUP

Barnhart 2004 9 9 % o f n l IU P s 1 d a y r is e ≥ 2 4 % 2 d a y r is e ≥ 5 3 % M e d ia n ris e : 1 d a y = 5 0 % 2 d a y = 1 2 4 %

Slowest expected 48-hour increase for normal pregnancy = 53% (20% of ectopics increase)

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β HCG trends : Other Key Points

• Two hcgvalues may not be enough
• If close to the thresholds –check another

Barnhart 2002

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Simplified Workup of Bleeding &/or Pain

1. Where is the pregnancy? à U/S (same day) 2. If the pregnancy undesired? à uterine aspiration 3. If desired and we can’t tell where it is: Is it normal or abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al – Serial beta HCGs:

• If Bhcgdrops > 50% in 48 hours = Abnorm

al

• If Bhcgrises > 50%

in 48 hours = M

• st likely norm

al (can be EP) – Continue to follow and repeat u/s

• If betw

een = M

• st likely abnorm

al (still can be norm al) – Continue to follow and repeat u/s

• 4. Once pregnancy clearly abnormal, if undesired or if

patient desires definitive dx à uterine aspiration

IU P=Intrauterine pregnancy

!

If Diagnose as Abnormal…

• Presumed ectopic pregnancy –uterine

aspiration before MTX

– High HCG & nothing in the uterus (50% SAB) – Very low HCG with abnormal rise or definite fall (25% SAB)

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Role of Ultrasound in Ectopic Diagnosis

• Only 2% of u/s are diagnostic for EP

– “Diagnostic” = Gestational Sac with yolk sac or fetal pole visualized outside uterus

• Normal adnexal exam does not exclude ectopic
• Suggestive of ectopic
• Empty uterus + hCG above discriminatory zone
• Complex mass + fluid in cul-de-sac (94% are EP)
• Should still follow them if desired pregnancy

Main role of U/S is to rule in IUP

!

Ultrasound Findings to R/o EP

• Remember that an EP has not been ruled out until

there is an intrauterine pregnancy – Gestational sac with a yolk sac and/or embryo

!

Simplified Workup of Bleeding &/or Pain

1. Where is the pregnancy? à U/S (same day) 2. If the pregnancy undesired? à uterine aspiration 3. If desired and we can’t tell where it is: Is it normal or abnormal? à quantitative (serial) Beta-HCG – If Bhcgabove threshold and no IUP = Abnorm al – Serial beta HCGs:

• If Bhcgdrops > 50% in 48 hours = Abnorm

al

• If Bhcgrises > 50%

in 48 hours = M

• st likely norm

al (can be EP) – Continue to follow and repeat u/s

• If betw

een = M

• st likely abnorm

al (still can be norm al) – Continue to follow and repeat u/s

• 4. Once pregnancy clearly abnormal, if undesired or if

patient desires definitive dx à uterine aspiration

IU P=Intrauterine pregnancy

!

In c

• m

p le te a b

• rtio

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• d

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• n
• b

ste tric c a u se

• f b

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• se

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• rtio

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P h y s ic a l e x a m B le e d in g in d e sire d p re g n a n cy , < 1 2 w e e k s g e sta tio n S e e F ig u r e 2 Figure 1. Evaluation of first-trimester bleeding P a tie n t sta b le , n

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r

• th

e r c a u se

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le e d in g N

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p le te d a b

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n ; e x p e c ta n t m a n a g e m e n t Reproductive Health Access Project/October 2013 www.reproductiveaccess.org

First-trimester Bleeding Algorithm

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R e p e a t β

• h

C G fe ll < 5 %

• r ro

se < 5 3 % * * * S u g g e sts c

• m

p le te d a b

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• h

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C G fe ll < 5 %

• r ro

se S in g leβ

• h

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• n

siste n t w ith h a v in g p a sse d P O C

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O b ta in h ig h

• le

v e l T V U S & se ria l b h C G sto d iffe re n tia te b e tw e e n e c to p ic , e a rly IU P , a n d re ta in e d P O C s’ tre a t a s in d ic a te d S in g leβ

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risin g a n d > 1 5 –2 * NO IUP or EP seen on TVUS IU P se e n

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p rio r T V U S ? Y e s N

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• m

p le te d a b

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n ; e x p e c ta n t m a n a g e m e n t Figure 2. Evaluation of first-trimester bleeding with no intrauterine pregnancy on ultrasound C

• n

tin u e d fr

• m

F ig u r e 1 * The β-hCGlevel at which an intrauterine pregnancy should be seen on transvaginalultrasound is referred to as the discrim inatory zone and varies between 1500 –2000 m IUdepending on the m achine and the sonographer. ** β-hCGneeds to be followed to zero only if ectopic pregnancy has not been reliably excluded. If a definitive diagnosis of com pleted m iscarriage has been m ade there is no need to follow further β-hCGlevels. *** In a viable intrauterine pregnancy there is a 99% chance that the β-hCGwill rise by at least 53% in 48 hours. In ectopic pregnancy, there is a 21% chance that the β-hCGwill rise by 53% in 48 hours. R e p e a t T V U S ; S e e T V U S in F ig u r e 1 Modified from Reproductive Health Access Project/October 2013 www.reproductiveaccess.org

First-trimester Bleeding Algorithm

If patient stable repeat bHCGand once higher than 3000 and no IUP –uterine aspiration to rule

• ut EPL and treat for EP if no IUP

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EPL Diagnosis, Counseling, and Management

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EPL – Making the diagnosis

Spontaneous abortion V aginal bleeding + IUP , <20 wks threatened, inevitable, incom plete, com plete Embryonic demise Em bryo with no cardiac activity Anembryonic gestation Gestational sac without em bryonic pole Clinical diagnosis: Ultrasound diagnosis:

!

Ultrasound Diagnosis of EPL: Anembryonic Gestation

Mean sac diameter >=21mm (20 mm = 0.5% false positive) AND no fetal pole (n>1000, 100% specificity)

Abdallah 2011

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Ultrasound Diagnosis of EPL: Embryonic Demise

Fetal pole >= 5.3 AND no cardiac activity

Abdallah 2011

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Fetal pole – 7 m m M SD – 25 m m

Radiologists in Ultrasound: Account for Margin of Error

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Ultrasound Milestones

Norm al IUP findings W hen should you see it? Abnorm ality if landm ark is absent Gestational Sac Discrim inatory Level β= 3,000? 3,500? Com pleted EPL M ultiple gestation Ectopic pregnancy Y

• lk sac

M SD > 13-16m m Suspicious for EPL Fetal pole M SD ≥ 21m m (n e w re c

2 5 d u e to v a r ia b ility )

Anem bryonicgestation Cardiac activity CRL ≥ 5.3m m

(n e w re c 7 m m )

Em bryonic dem ise Interval grow th (M SD or CRL) 1 m m /day

(o v e r 3 -7 d a y s )

Confirm ed EPL

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Patient Case: Counseling

• Maya was diagnosed with an embryonic demise.
• How do we counsel her about management options?

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EPL Management

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EPL Management: A Preference-Sensitive Decision

• Best choice for management reflects the woman’s

values and preferences

• Patients have strong and widely divergent preferences

– Challenges in recruitm ent for RCT s – Higher satisfaction when treated according to patient’s preference

Wieringa-de Waard 2002; Dalton 2006; Smith 2006

Expectant Medication Office-based aspiration Operating room aspiration

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EPL Management: Patient Preferences

No ‘one best way’ to treat miscarriage that suits all individuals. Expectant management is preferred

• ver aspiration by 40-70% of women.

When aspiration is indicated or preferred, the majority of women will choose an office-based procedure over

• ne in the OR.

Smith 2006; Wieringa-de Waard 2002; Dalton 2006

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Research on EPL Counseling

• Women want unbiased and comprehensive counseling about
• ptions for this preference-sensitive decision.
• Women perceive communication during EPL diagnosis as a

critical time to initiate discussions of management.

• Women are often weighing personal priorities to make

decisions about EPL management.

• Use of a decision aid may offer a systematic counseling

approach for a patient-centered decision-making process.

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Early Pregnancy Failure: Counseling

• Women blame themselves (“was it the stress?”)
• Wonder if will happen again

Patient counseling should include:

• How common it is (encourage to talk to friends)
• Reassurance that it is beyond her control and unlikely to

recur (“Nothing could have been done to prevent it.”)

• Acknowledge/validate grieving
• No need to wait to attempt another pregnancy- ok to try

after resumption of menses (when emotionally ready)

!

Patient Treatment Priorities for Miscarriage

Personal Priorities Medications and Procedure-related Factors Time and Cost Priorities Symptoms of Pain and Bleeding Past Abortion or Miscarriage (if applicable)

I Treatment by your own provider I Recommendation of treatment from friend or family member I Provider recommendation of treatment I Lowest risk of need for other steps I Family responsibilities/needs I Most natural process I Lowest risk of complications I Avoid invasive procedure I Avoid medications with side effects I Avoid going to sleep in case of a surgical procedure I Want to be asleep in case of a surgical procedure I Avoid seeing the pregnancy tissue I Shortest time before miscarriage is complete I Shortest time in the clinic or hospital I Fastest return to fertility or normalcy I Fewest number of clinic visits I Lowest cost of treatment to you I Least amount of pain possible I Experience symptoms of bleeding and cramping in private I Least amount of bleeding I Different treatment from previous I Similar treatment to previous Having a miscarriage is extremely difficult for most women. This worksheet is intended to help you and your provider choose a treatment that will make you the most comfortable. Please circle any of the priorities below that you consider important in managing your miscarriage. !

Early Pregnancy Loss (EPL) Management

• Four options for the clinically stable patient
• 1. Aspiration w/ general/deep sedation (operating room

)

• 2. Aspiration w/ local/m
• derate sedation (office-based)
• 3. M

edication (m isoprostol)

• 4. Expectant
• All methods are effective, with equivalent safety and

patient acceptability = clinical equipoise

NSFG 2004; Chen 2007; Wieringa-de Waard, 2002; Zhang 2005; Trinder 2006

!

Reference: Helping your patient to choose treatment for EPF

Medical Management: Mife+Miso or Miso alone Advantages: P riv a c y, availability , m

• st can avoid surgical tx, decreased infection

Disadvantages: M ultiple visits, 30% 2

nd dose, m

• re pain, M
• re N/V & bleeding

Misoprostol alone: 800mcg pv, repeat if needed: 8-d success: 75% Mife (200 mg po)+Miso @ 24 hrs (800 pv): 8-d success: 90% Uterine Aspiration: Success: ~100% Advantages: 2-4 hrs, high success rate, less blding& pain Disadvantages: Less available, rare surgical com plications, increased infection Expectant: Success: 66% at 2wks. Advantages: Privacy , som e can avoid surgical treatm ent, decreased infection Disadvantages: Up to 6 wksto com plete, m

• re bleeding & visits, less satisfaction

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Expectant Management

• “Watchful waiting”
• Proven safety up to 8 weeks
• Type of EPL affects expected efficacy

(incomplete>anembryonic gestation>embryonic demise)

• Acceptable to patients with realistic expectations about:

Duration, Discomfort, and potential D&C

!

Expectant Management

Advantages

• Non-invasive
• Body naturally expels non-

viable pregnancy

• Avoids anesthesia and

surgery risks

• Allows for patient privacy

and continuity of care Disadvantages

• Unpredictable outcome

and timescale

• Process can last days to

weeks

• Can have prolonged

bleeding and cramping

• Despite waiting, may still

need uterine aspiration

!

Expectant Management

Contraindications

• Uncertain diagnosis
• Suspected gestational

trophoblastic disease

• Indicated karyotyping
• Severe hemorrhage or pain
• Infection
• IUD in place

Same contraindications for medication management

!

Medication Management

• Use of medications for active management of EPL
• Misoprostol

– Stimulates uterine contractions & softens cervix – Inexpensive, easy storage

• Mifepristone

– Anti-progestin used for pregnancy termination – New study supports use

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Medication Management

Advantages

• Highly cost-effective
• Non-invasive
• Safe
• Can be highly effective
• Avoids anesthesia and

surgery risks

• Allows for patient privacy

and continuity of care Disadvantages

• Increased need for

analgesics and pain control

• May cause heavier or longer

bleeding

• May cause short-term

gastrointestinal and other side effects

• May still need uterine

aspiration

!

Practice Integration for Medication Management

• Evaluation

– Exam, lab, or sono?

• Medications

– Dispensed in clinic or Rx?

• 24 hour call service
• Back-up plan for aspiration

– Emergent vs. non-urgent

• Follow-up plan

!

Misoprostol for EPL

Recommended in ACOG Practice Bulletin 800 mcg vaginally (PV) with

• ptional repeat dose >3 hours

later if no initial response

!

Mifepristone before Misoprostol for EPL

New study in NEJM 200 mg Mifepristone + 800 mcg Miso (PV) 24 hours later

SLIDE 14

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Mifepristone Pretreatment

• RCT of 300 women
• 200 mg po Mifepristone followed by Misoprostol 800mcg pv

24 hours later

• Followed up in 1-4 days
• If persistent sac offered repeat misoprostol v. expectant v.

aspiration

!

Mifepristone Pretreatment

!

Medications for Symptoms and Side Effects

Cramping Ibuprofen 600 mg Q6 hrs or 800 mg Q8 hrs (or other NSAID) Severe cramping pain not relieved by ibuprofen Hydrocodone/APAP 5/500 or 5/325 Q 4-6 hrs prn Nausea/vomiting Promethazine 25 mg Q 4-6 hrs prn or other anti-emetic

!

Typical Follow-Up

Phone contact Call patient 1-2 days after first m isoprostol dose to assess need for second dose. In-person visit 1-2 w eeks after choosing expectant or m edication m anagem ent to assess:

• 1. If m

iscarriage is not com plete –Ispatient interested in alternate treatm ents?

• 2. Confirm

com pletion(see below) Confirm ing com pletion

• 1. Clinical history consistent with com

plete m iscarriage plus β-hCGdecline of >50% or negative urine pregnancy test

• 2. Clinical history plus disappearance of intrauterine

pregnancy on transvaginalultrasound

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EPL Expectant/Medical Management

• Clinical checklist for care options:

– Clear diagnosis – Patient is stable – Access to phone & emergency care – Pain control options available – Anticipatory guidance for bleeding, s/sx infection – Rh status – Reliable follow-up

!

Aspiration for EPL

• Historically done in operating room under general

anesthesia

• Terminology:

– Surgical “D&C” – Suction curettage with manual or electric vacuum aspiration

!

Operating Room Aspiration

Advantages

• Predictable
• Offers fastest resolution of

m iscarriage

• Reduced duration of bleeding
• Low risk (<5%) of needing further

treatm ent

• Can be asleep

Disadvantages

• Rare risks associated with

invasive procedure and general anesthesia

• More cost than office-based

procedures

• More time and physical exams

than office-based procedures

• May be more bleeding

complications under general anesthesia than in office-based procedures

!

Office-based Aspiration

Advantages

• Predictable
• Offers fastest resolution of

m iscarriage

• Reduced duration of bleeding
• Low risk (<5%) of needing

further treatm ent

• Pain control with local plus oral
• r IV m

eds Disadvantages

• Rare risks of invasive procedure
• Less pain control options in som

e settings Com pared to O R m anagem ent:

• M

ay allow im proved patient access and continuity of care

• Im

proved privacy

• Less patient and staff tim

e

• Resource and cost savings

SLIDE 16

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Patient Case: Management

• How do we manage Maya?
• Chance of success for embryonic demise:

– Expectant à 1 week (30%) 2 weeks (60%) 6 weeks (75%) – Medical à 1 week (88%) – Aspiration à In office or OR (97-100%)

!

EPL: Patient-Centered Care

• 1. Keep her informed throughout the diagnostic work-up
• 2. Use clear but compassionate language
• 3. Be prepared to discuss management options at dx
• 4. Present advantages and disadvantages of each
• 5. Facilitate recognition of patient’s priorities
• 6. Ensure follow-up and allow opportunity to change

management decision

!

Patient Case: Management

• Maya chose to use mifepristone followed by misoprostol

at home 24 hours later

• She placed the misoprostol pills vaginally and began

having cramping and bleeding 2 hours later

• Her heavy bleeding lasted 4 hours, and she noticed one

particularly large clot

• She still has some light bleeding at her follow-up

appointment, 7 days later How do we confirm success of treatment?

!

EPL Management: Follow-up

• Use both history and exam to confirm completion

– β-HCG drop >50% in 48 hours or negative UPT @ 2-4 wks – Vaginal ultrasound

• Treat the patient, not the ultrasound
• Address fertility desires

– Contraception vs prenatal vitamins

• Offer grief counseling follow-up or referrals

SLIDE 17

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Vaginal Ultrasound

*Thickness of endometrium NOT associated with need for future intervention

!

ACOG Practice Bulletin Early Pregnancy Loss (May 2015)

Level A

• 800 mcg misoprostol for medical management
• Use of anticoagulants doesn’t reduce risk

Level B

• US preferred modality to verify viable IUP
• D&C not required for thick stripe after treatment if

asymptomatic

• Rh- patients should receive Rhogam

Level C

• Can safely accommodate preferences
• Doxycyline before surgical management

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Explore the resource page and link to the learning module: www.earlypregnancylossresources.org

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Ectopic Pregnancy Management

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Treatment of EP

Surgery

• If hemodynamically unstable, patient desires surgery,

contraindications to or failed MTX treatment

• Laparoscopy (or laparotomy)
• Salpingectomy or salpingostomy

– Salpingectomy if tube significantly compromised

• 10% failure rate if salpingostomy, require b-hcg followup

Expectant management

• If beta HCG <200 88% resolve spontaneously
• Declining beta HCG - third value less than first
• Asymptomatic, informed consent

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Medical Treatment of EP

Methotrexate

• Antimetabolite that interrupts DNA

synthesis in actively dividing tissues

• Successful in 80-95%
• Beta HCG levels >5000 higher failure

rate with single-dose tx (14% v. 4% if less than 5000)

• Single-, two-, multi-dose regimens
• Start with single-dose if b-hcg <5000
• Multi-dose for cervical or interstitial

ectopics

A ls o : In a b ility to fo llo w -u p ACOG Practice Bulletin # 94

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Lipscomb 1999

Serum β-hCG Success Rate

<1,000 98% (118/120) 1,000-1,999 93% (40/43) 2,000-4,999 92% (90/98) 5,000-9,999 87% (39/45) 10,000-14,999 82% (18/22) >15,000 68% (15/22)

Success of Single Dose MTX for EP

SLIDE 19

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Conclusion

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Conclusions

• Bleeding in early pregnancy is common.
• Take possibility of ectopic pregnancy seriously!
• Pregnancy of unknown location takes patience to sort out.

– New beta-HCG cutoffs – New ultrasound m easurem ent cutoffs – If abnorm al –do uterine aspiration before giving M TX

• Patient preference is important.
• If medical management, use mifepristone.

Thanks to Robin Wallace, Carolyn Sufrin, Meg Autry, Rebecca Jackson