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Diagnosis and Management of Ectopic Pregnancy (GTG 21 - Nov 2016),…

- - - - Laparoscopy > Open
      - Salpingectomy > Salpingotomy (if healthy contralateral tube)
      - Consider salpingotomy in women with fertility-reducing factors: Previous ectopic, contralateral tubal damage, previous abdominal surgery, previous PID
      - Salpingotomy: Inform of risk of persistent trophoblast (3.9-11%) with need for BHCG follow-up (7 days after surgery then weekly until negative result), and risk of further treatment with methotrexate or salpingectomy
    - - Suitability
        
        Haemodynamic stability
        
        Willingness to attend for follow-up
        
        No known sensitivity to methotrexate
        
        NICE: No significant pain, serum HCG 1500-5000, unruptured ectopic <35mm, no IUP, no fetal cardiac activity
      - Single IM methotrexate 50mg
        Success rate 65-95%, 3-27% requiring 2nd dose
      - Repeat serum HCG 48 hours apart: Check that HCG not rising at a rate consistent with viable IUP
        DO NOT GIVE AT FIRST VISIT; EXCLUDE VIABLE IUP
      - Measure BHCG levels on D4 and D7 post-methotrexate: If BHCG decreases by >15% between D4 and D7, then measure weekly until <15, if not then repeat transvaginal ultrasound +/- treatment
      - Common SE: Flatulence, bloating, elevated liver enzymes, stomatitis
        Others: Marrow suppression, pulmonary fibrosis, liver cirrhosis, renal failure, gastric ulceration
      - Contraindications
        
        Haemodynamic instability
        
        Presence of IUP
        
        Breast-feeding
        
        Unable to comply to follow-up
        
        Sensitivity to methotrexate
        
        Chronic liver disease
        
        Immunodeficiency
        
        Peptic ulcer disease
        
        Pre-existing blood dyscrasia
        
        Active pulmonary disease
    - - Clinically stable women with ultrasound diagnosis of
        ectopic pregnancy and a decreasing b-hCG level initially <1500
      - Must be willing and able to attend follow-up, have minimal pain, and have low or declining serum BHCG levels
      - Sucess rates inversely proportional to serum BHCG levels: Lower success rates associated with higher initial BHCG levels