09.10.2015

Methotrexate for ectopic pregnancy reviews

Cotinine exposure increases Fallopian tube PROKR1 expression via nicotinic AChRalpha-7: a potential mechanism explaining the link between smoking and tubal ectopic pregnancy. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France.
Diagnosis and management of ectopic pregnancy [published correction appears in Am Fam Physician. Clinical factors affecting the accuracy of ultrasonography in symptomatic first-trimester pregnancy. When a pregnant patient presents with first-trimester bleeding or abdominal pain, physicians should consider ectopic pregnancy as a possible cause.
Although these also may occur in intrauterine pregnancy and spontaneous abortion, physicians must consider ectopic pregnancy when a pregnant woman presents with these symptoms.
For patients who are medically unstable or experiencing life-threatening hemorrhage, immediate surgical treatment is indicated. The clinical history should focus on pregnancy dating, the onset and intensity of symptoms, and a review of risk factors for ectopic pregnancy. Clinical manifestations, diagnosis, and management of ectopic pregnancy [subscription required]. When ultrasonography does not clearly identify the pregnancy location, the physician must determine whether the pregnancy is intrauterine (either viable or failing) or ectopic. For example, dating is important because a physician may wish to order ultrasonography in a patient with a suspected ectopic pregnancy at eight to 10 weeks' gestation in an attempt to identify the location of the pregnancy.


Failure to visualize an intrauterine pregnancy when β-hCG is above the discriminatory level suggests ectopic pregnancy.
Conversely, ultrasonography is less likely to be useful for confirming pregnancy location at four weeks' gestation.
For this reason, any woman of childbearing age who presents with abdominal pain or abnormal vaginal bleeding should be evaluated for pregnancy as part of the initial examination.PHYSICAL EXAMINATIONPhysical examination should be used to detect peritoneal signs, such as rebound tenderness and cervical motion tenderness, which indicate the possibility of hemoperitoneum.
The remaining 1% of patients have a slower rate of increase; these patients may have pregnancies that are misdiagnosed as nonviable intrauterine or ectopic.
Abdominal pain with peritoneal signs in a pregnant patient should prompt an immediate evaluation by a gynecologist to determine the need for emergency surgery.Inspection of the cervical os for bleeding and evidence of products of conception in the vagina helps differentiate spontaneous abortion from ectopic pregnancy. After an ectopic pregnancy has been confirmed, treatment options include medical, surgical, or expectant management. Pathologic evaluation of tissue retrieved from the vagina is critical to avoid misdiagnosing a decidual cast as products of conception.IMAGINGTransvaginal ultrasonography is the recommended imaging technique for patients with suspected ectopic pregnancy. For patients who are medically unstable or experiencing life-threatening hemorrhage, a surgical approach is indicated. For others, management should be based on patient preference after discussion of the risks, benefits, and monitoring requirements of all approaches.
The diagnostic challenge occurs when ultrasonography does not identify a pregnancy as intrauterine (either viable or failing) or ectopic, resulting in the diagnosis of pregnancy of unknown location. Ectopic pregnancy, a high-risk condition in which a fertilized ovum implants outside the uterine cavity, affects 1% to 2% of all pregnancies and poses a significant threat to women of reproductive age. The approach to a pregnancy of unknown location requires a balance of benefits and risks (Figure 12,12,13).


Early treatment reduces morbidity from a ruptured ectopic pregnancy, but risks overtreating an evolving spontaneous abortion or interrupting a viable pregnancy.
Conversely, longer periods of observation improve the ability to determine the location, but this may come at the expense of morbidity from a later diagnosis of ectopic pregnancy.
Because methotrexate exerts its greatest effect on rapidly dividing cells, gastrointestinal adverse effects, such as gastric pain, nausea, vomiting, and stomatitis, are the most common. This is the value above which an intrauterine pregnancy should be visualized by ultrasonography. After methotrexate administration, the β-hCG level should decrease by at least 15% from day 4 to day 7 after injection. Serial measurements of β-hCG can be used to evaluate a pregnancy of unknown location.
However, it is not uncommon for the β-hCG level to initially plateau or increase before it begins to decrease.
However, 1% of patients with viable intrauterine pregnancy have a slower rate of increase.19  These patients often receive a misdiagnosis of nonviable intrauterine or ectopic pregnancy. A blood type and screen should be obtained on all women with suspected ectopic pregnancy to determine Rh status.
All women with Rh-negative results who experience bleeding should receive RhO(D) immune globulin (RhoGam), regardless of the final outcome of the pregnancy, to protect against development of Rh alloimmunization.LAPAROSCOPYIn the absence of major risk factors or concerning physical findings, the location of a pregnancy should be determined within seven to 10 days.



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