Medication
Medication An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. The medication is given by injection. It's very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment.
Procedures
Ectopic pregnancy (EP) is the most common cause of death in the first trimester of pregnancy. Methotrexate (MTX) is an acceptable treatment in the cases with the lack of tube rupture or no important one, which has reduced surgical treatment.
Self-care
Studies suggest that around 60% of women affected by an ectopic pregnancy go on to have a viable IUP.79This figure includes those who do not plan to have another pregnancy and so the proportion will be higher if further pregnancy is planned.
How do you treat ectopic pregnancy without bleeding?
The ectopic pregnancy is removed and the tube is either repaired (salpingostomy) or removed (salpingectomy). Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured.
Can methotrexate be used to treat ectopic pregnancy?
What percentage of ectopic pregnancies have a viable IUP?
What is the procedure for ectopic pregnancy?
What is the most common treatment for ectopic pregnancy?
The most common drug used to treat ectopic pregnancy is methotrexate. This drug stops cells from growing, which ends the pregnancy. The pregnancy then is absorbed by the body over 4–6 weeks. This does not require the removal of the fallopian tube.
What is the injection for ectopic pregnancy?
Methotrexate is a type of medicine that stops cells from dividing. It can be used as a way (other than surgery) to treat a pregnancy that's implanted outside the uterus (ectopic pregnancy). It's given by injection, and usually just 1 dose is given.
Which medication is used to treat an unruptured ectopic pregnancy?
The standard medical treatment for unruptured ectopic pregnancy is methotrexate therapy. Methotrexate is an antineoplastic agent that inhibits cell proliferation by destroying rapidly dividing cells.
What is the usual treatment for a ruptured ectopic pregnancy?
The internal haemorrhage that occurs due to rupture of an ectopic pregnancy may be life-threatening. Surgery is considered to be the gold standard of treatment for ruptured ectopic pregnancy.
Where is methotrexate injection given?
The medicine is given as a shot under your skin, usually on the stomach or thigh. Use a different body area each time you give yourself a shot. Keep track of where you give each shot to make sure you rotate body areas. This will help prevent skin problems from the injection.
What is methotrexate for ectopic pregnancy?
What is methotrexate? It is a medicine that can be used to treat an ectopic pregnancy. It stops cells from dividing by interfering with the folic acid in your body. It is given by injection.
Where do they inject methotrexate for ectopic pregnancy?
To treat ectopic pregnancy, methotrexate is typically given as an injection (a shot) into a muscle. This often takes place in a hospital emergency room. In some cases, a second or third injection is necessary in the weeks after the first injection. Most ectopic pregnancies occur in a fallopian tube.
Is surgery or methotrexate better for ectopic pregnancy?
Methotrexate is the medication used to dissolve the ectopic, and under the right circumstances, it has the advantage of avoiding invasive laparoscopic surgery. It is safe, appropriate, and very effective for healthy women with un-ruptured smaller pregnancies.
What is methotrexate used for?
Methotrexate is a type of medicine called an immunosuppressant. It slows down your body's immune system and helps reduce inflammation. It is used to treat inflammatory conditions, including: rheumatoid arthritis.
What will be the hCG level in ectopic pregnancy?
Absence of an intrauterine gestational sac on abdominal ultrasound in conjunction with a β-hCG level of greater than 6,500 mIU per mL suggests the presence of an ectopic pregnancy.
At what hCG level does an ectopic rupture?
Expectant management However, about 90% of women with ectopic pregnancy and serum β-hCG levels greater than 2000 IU/L require operative intervention owing to increasing symptoms or tubal rupture. Tubal rupture can also occur when serum β-hCG levels are low or declining, or both.
Do you bleed after methotrexate for ectopic?
A few days after the injection, it is usual to begin to bleed and this bleeding can last between a few days and up to 6 weeks. It is usual to have some discomfort and pain initially but as long as this is not severe. If your pain is severe, please come into hospital immediately.
How does ectopic pregnancy improve?
Diagnosis of ectopic pregnancy has improved significantly due to advances in ultrasound technology, rapid and sensitive serum hormone assays, the development of EPUs and an increased awareness and understanding of the associated risk factors. Despite this, around half of the women with an eventual diagnosis of ectopic pregnancy are not diagnosed at their first presentation.31,32Early diagnosis reduces the risk of tubal rupture and allows more conservative medical treatments to be employed.1,33
What is ectopic pregnancy?
An ectopic pregnancy occurs when a fertilised ovum implants outside the normal uterine cavity.1-3 It is a common cause of morbidity and occasionally of mortality in women of reproductive age. The aetiology of ectopic pregnancy remains uncertain although a number of risk factors have been identified.4Its diagnosis can be difficult.
What are the risk factors for ectopic pregnancy?
These factors include any previous pelvic or abdominal surgery, and pelvic infection. 11Ch lamydia trachomatishas been linked to 30-50% of all ectopic pregnancies.12The exact mechanism of this association is not known but it has been proposed that in addition to distortion of tubal architecture, it may to be due to an effect on the tubal microenvironment.13
How to diagnose an unruptured ectopic pregnancy?
Currently, diagnosis in unruptured ectopic pregnancy is achieved using a combination of transvaginal ultrasonography and measurement of serum β-hCG concentrations. One of the key elements in the diagnosis is the exclusion of a viable or non-viable IUP. Diagnosis can be straightforward when a transvaginal ultrasound scan (TVS) positively identifies an IUP or ectopic pregnancy34(Figure 1). However, TVS fails to identify the location of a pregnancy in a significant number of women and such women are currently diagnosed as having a ‘pregnancy of unknown location’ (PUL).35,36
How accurate is IUP ultrasound?
High-definition ultrasonography, particularly using the transvaginal route, has revolutionised the assessment of patients with early pregnancy problems, allowing for clearer visualisation of both normal and abnormal gestations.39In a healthy IUP, a TVS should identify the intrauterine gestation sac with almost 100% accuracy at a gestational age of 5.5 weeks.40,41Even so, it is recognised radiographic practice that an IUP is only definitively diagnosed by ultrasound visualisation of a yolk sac or embryo in addition to a gestation sac.42-44This is because an ectopic pregnancy can be accompanied by a ‘pseudosac’, a collection of fluid within the endometrial cavity that may be the result of localised breakdown of the decidualised endometrium. However, its central location within the endometrial cavity distinguishes it from the very early gestation sac that is typically eccentrically placed.45In addition, pseudosacs are transient rather than consistent and they do not have a hyperechoic decidual reaction around them. Additional embryonic features including the yolk sac and cardiac activity should be clearly visible after 6 weeks’ gestation. A sonographer with experience in early pregnancy scanning should generally be able to tell the difference between a pseudosac and an empty early intrauterine sac.
How long does it take for a woman to have pain during ectopic pregnancy?
Patients with an ectopic pregnancy commonly present with pain and vaginal bleeding between 6 and 10 weeks’ gestation.1However, these are common symptoms in early pregnancy, with one third of women experiencing some pain and/or bleeding.22-24The pain can be persistent and severe and is often unilateral.
How many ectopic pregnancies are there in the world?
In the developed world, between 1% and 2% of all reported pregnancies are ectopic pregnancies (comparable to the incidence of spontaneous twin pregnancy).7The incidence is thought to be higher in developing countries, but specific numbers are unknown. Although the incidence in the developed world has remained relatively static in recent years, between 1972 and 1992 there was an estimated six-fold rise in the incidence of ectopic pregnancy.8This increase was attributed to three factors: an increase in risk factors such as pelvic inflammatory disease and smoking in women of reproductive age, the increased use of assisted reproductive technology (ART) and increased awareness of the condition, facilitated by the development of specialised early pregnancy units (EPUs).
When was methotrexate used?
Methotrexate (MTX) has been used in clinical practice as a medical treatment option in these pregnancies since 1982 (Tanaka et al., 1982 ). However, there is no consensus in the on the human Chorionic Gonadotropin (hCG) threshold above which MTX use is not recommended (Bonin et al., 2017).
Is methotrexate used for ectopic pregnancy?
Use of methotrexate in the treatment of ectopic pregnancies: a retrospective single center study
What is an ectopic pregnancy?
Ectopic pregnancy (EP) is a “can’t miss diagnosis” and the leading cause of maternal death in the first trimester. It results from the fertilized ovum implantation outside of the endometrium of the uterus. Although ectopics are most commonly found in the fallopian tubes, they can also occur in the ovary, cervix, myometrial interstitium, and peritoneal cavity. This potentially life-threatening condition occurs in up to 2% of all pregnancies.
What should be done for a suspected EP?
The initial evaluation of a patient with a suspected EP should focus on the rapid assessment of vital signs and the ABCs. The patient should be placed on monitors, and intravenous (IV) access should be obtained. Depending on the patient’s hemodynamic status, IV fluids or blood products may be necessary. In those with evidence of hemorrhagic shock, O negative blood may need to be transfused and massive transfusion protocols initiated. Narcotic analgesia should be administered as needed for pain control.
Does a transvaginal ultrasound reveal an IUP?
Case Study: The patient’s β-hCG was 5000 mIU/mL. Although transvaginal ultrasound did not reveal an IUP, an adnexal mass containing a yolk sac was visualized. The patient was Rh-positive and, therefore, did not require RhoGAM. After OB-GYN consultation, the decision was made to administer methotrexate since the patient was hemodynamically stable, had no evidence of ruptured EP, and had no contraindications to medical management. The patient was discharged home with “ectopic return precautions.” After close follow up with OB-GYN, serial β-hCG levels were found to be decreasing appropriately.
Can methotrexate be used for EP?
Stable patients with EP may be managed medically with methotrexate. Medical management may preserve future fertility better than surgery. This agent interferes with DNA synthesis and replication of fetal cells, resulting in involution of the pregnancy. 36% of patients fail single dose therapy and require a second dose if β-hCG levels are not declining as expected.
Can ultrasound be used to diagnose EP?
As stated earlier, bedside FAST can identify free fluid in the abdomen/pelvis, raising the concern for ruptured EP. Ultrasound can also be used to visualize the presence or absence of an IUP. Unless a concern for heterotopic pregnancy exists (i.e., concurrent EP and IUP), the presence of an IUP rules out EP. Although heterotopic pregnancies are rare overall (1/10,000-30,000 natural conceptions), assisted reproductive technology rates may be as high as 1/100.
What is ectopic pregnancy?
ECTOPIC PREGNANCY IS A LIFE- AND FERTILITY-threatening condition that is commonly seen in Canadian emergency departments. Increases in the availability and use of hormonal markers, coupled with advances in formal and emergency ultrasonography have changed the diagnostic approach to the patient in the emergency department with first-trimester bleeding or pain. Ultrasonography should be the initial investigation for symptomatic women in their first trimester; when the results are indeterminate, the serum β human chorionic gonadotropin (β-hCG) concentration should be measured. Serial measurement of β-hCG and progesterone concentrations may be useful when the diagnosis remains unclear. Advances in surgical and medical therapy for ectopic pregnancy have allowed the proliferation of minimally invasive or noninvasive treatment. Guidelines for laparoscopy and for methotrexate therapy are provided.
How does ectopic pregnancy resolve?
Ectopic pregnancy can resolve spontaneously through regression or tubal abortion. However, about 90% of women with ectopic pregnancy and serum β-hCG levels greater than 2000 IU/L require operative intervention owing to increasing symptoms or tubal rupture.3,4Tubal rupture can also occur when serum β-hCG levels are low or declining, or both.45Expectant management should be offered only when transvaginal ultrasonography fails to show the location of the gestational sac and the serum levels of β-hCG and progesterone are low and declining. Because of the possibility of tubal rupture, these patients must be carefully monitored until the serum β-hCG concentration falls below 15 IU/L; at this point almost all ectopic pregnancies resolve spontaneously, without rupture.
How accurate is a transvaginal ultrasound?
Many prospective studies have shown that “formal” transvaginal ultrasound imaging (i.e., that performed by ultrasound technicians and interpreted by radiologists) in the emergency department has high accuracy in confirming intrauterine and ectopic pregnancy. Most protocols can establish a diagnosis with the initial scan in more than 75% of emergency department patients.23,35,40A diagnosis can often be established even in the subgroup of patients with β-hCG levels below the discriminatory threshold. In some studies, transvaginal scanning has identified up to one-third of the patients with below-threshold β-hCG levels who had ectopic pregnancy.35,41Given the likelihood of a definitive diagnosis, even with below-threshold β-hCG levels, ultrasonography is the best initial investigation in problematic early pregnancy.
What is the discriminatory threshold for ectopic pregnancy?
The concept of the discriminatory threshold (the β-hCG level at which an intrauterine gestational sac can be reliably seen in a normal pregnancy) has existed since the early 1980s.33A β-hCG level that has risen above the discriminatory threshold in the absence of sonographic signs of early pregnancy is considered presumptive evidence of an ectopic pregnancy. With the evolution in ultrasound technology, the discriminatory threshold has dropped from 6500 IU/L with a transabdominal approach to between 1000 and 2000 IU/L with transvaginal imaging.34This threshold is user- and machine-dependent and thus will vary slightly from institution to institution. Caution should be used in assuming an ectopic pregnancy when a nondiagnostic ultrasound image accompanies a single β-hCG level above the discriminatory threshold: several articles have reported a small number of patients with indeterminate ultrasound images and β-hCG levels above the threshold who have been eventually found to have a viable intrauterine pregnancy.34,35,36In addition, there could be unseen multiple intrauterine gestational sacs, since the β-hCG values relative to gestational age are higher in patients with multiple embryos.37
How to visualize gestational sac?
A normal gestational sac, an ovoid collection of fluid adjacent to the endometrial stripe, can be visualized by means of the transvaginal probe at a gestational age of about 5 weeks. It can often be seen when 2 or 3 mm in diameter and should be consistently seen at 5 mm. Since the hormonal environment in ectopic pregnancy can produce an intrauterine fluid collection that mimics a gestational sac (the “pseudogestational sac” shown in Fig. 1, arrow), a sac alone cannot confirm intrauterine pregnancy.32
What is the most common life threatening emergency in early pregnancy?
Ectopic pregnancy , in which the gestational sac is outside the uterus, is the most common life-threatening emergency in early pregnancy. The incidence in the United States has increased greatly in the last few decades, from 4.5 per 1000 pregnancies in 1970 to an estimated 19.7 per 1000 pregnancies in 1992.1,2Although spontaneous resolution of ectopic pregnancy can occur, patients are at risk of tubal rupture and catastrophic hemorrhage.3,4Ectopic pregnancy remains an important cause of maternal death, accounting for about 4% of the approximately 20 annual pregnancy-related deaths in Canada.5Despite the relatively high frequency of this serious condition, early detection can be challenging. In up to half of all women with ectopic pregnancy presenting to an emergency department, the condition is not identified at the initial medical assessment.6Although the incidence of ectopic pregnancy in the general population is about 2%, the prevalence among pregnant patients presenting to an emergency department with first-trimester bleeding or pain, or both, is 6% to 16%.7,8,9,10,11,12,13,14Thus, greater suspicion and a lower threshold for investigation are justified.
When is ectopic pregnancy diagnosed?
Ectopic pregnancy is usually diagnosed in the first trimester of pregnancy. The most common gestational age at diagnosis is 6 to 10 weeks, but fetal viability can be discovered until the time of delivery.15,16Ectopic pregnancy has about the same frequency across a wide range of maternal ages and ethnic origins. Documentation of risk factors (Table 19,17,18) is an essential part of history-taking, and asymptomatic clinic patients with risk factors may benefit from routine early imaging.19However, more than half of identified ectopic pregnancies are in women without known risk factors.8,9
Drugs used to treat Ectopic Pregnancy
The following list of medications are in some way related to, or used in the treatment of this condition.
Further information
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
What to do if you have an early ectopic pregnancy?
Medication. An early ectopic pregnancy may be managed with medicine. If you have low levels of hCG -- a hormone your body makes when you’re pregnant and there’s no damage to the fallopian tube -- your doctor can give you an injection of a drug called methotrexate ( Trexall ).
Why are ectopic pregnancies called tubal pregnancies?
Whether there’s a problem with the egg or the tube, the egg gets stuck on its journey to the uterus. A pregnancy can’t survive outside of the uterus, so all ectopic pregnancies must end.
Can a pregnancy survive outside of the uterus?
A pregnancy can’t survive outside of the uterus, so all ectopic pregnancies must end. It used to be that about 90% of women with ectopic pregnancies had to have surgery. Today, the number of surgeries is much lower, and many more ectopic pregnancies are managed with medication that prevents them from progressing.
Can you save a fallopian tube?
If your tube has ruptured or been severely damaged, the surgeons might have to remove your fallopian tube. Sometimes, the tube may be saved if damage is minimal. After surgery, your doctors will watch your hCG levels to make sure they’re going down and the pregnancy was removed properly.
What is an ectopic pregnancy?
Ectopic pregnancy (EP) is the implantation of blastocyst out of uterus; 95% of EP implantation is in the fallopian tube and others in the ovary, peritoneal cavity, cervix, and scar of cesarean section.
What is the treatment for EP?
Treatment of EP can be medical or surgical. Medical treatment is the prescription of methotrexate (MTX) and surgery includes salpingostomy or salpingectomy. The type of treatment depends on the stability or instability and desire of the patient. There are several protocols for prescription of MTX in stable patients; single-, double-, multiple-dose, and injection of MTX in EP sac. MTX is an antagonist of folic acid and inhibits dihydrofolate reductase and prevents the proliferation of trophoblasts, but it has some side effects such as liver involvement, stomatitis, gastroenteritis, and bone marrow suppression. The best protocol has been a puzzle for physicians. Thus, we decided to compare the effects and side effects of single- and multiple-dose regimens in the treatment of EP.[3] The success rate of medical treatment has reported as between 75% and 96% in properly selected patients.[4] The multi-dose regimen includes the administration of maximum 4 dose of MTX with folinic acid.[5,6] whereas the single-dose protocol comprises a single dose of MTX, which can be repeated in nonresponders without of fulinic acid.[7]
What is the diagnosis of EP?
EP diagnosis was based on the serum levels of βHCG and transvaginal sonography. If the βHCG levels was >1500 mIU/mL, but there wasn't any gestational sac in the uterus or ectopic sac was seen in outside of the uterus, or increasing βHCG levels within 48 h were <66%, the diagnosis of EP was made.[14]
When is MTX prescribed?
However, in the two-dose or multiple-dose method, MTX is prescribed regardless of the decrease in serum βHCG level until day 4, and the other procedures are similar to the single-dose method, and surgery is recommended if there is no response to treatment and lack of appropriate reduction.
How much does HCG drop on day 4?
hCG declines 15% between day 4 and 7
Is methotrexate safe for pregnancy?
Ectopic pregnancy (EP) is the most common cause of death in the first trimester of pregnancy. Methotrexate (MTX) is an acceptable treatment in the cases with the lack of tube rupture or no important one, which has reduced surgical treatment. Despite numerous studies, there is still no consensus about medications.
Case Study
Objectives
Introduction
Initial Actions and Primary Survey
Specialist to consult
Presentation
- A fertilized egg can't develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery o…
Diagnostic Testing
Treatment
Pearls and Pitfalls
Case Resolution
References