1 / 65

Pregnancy of Unknown Location “PUL”

Pregnancy of Unknown Location “PUL”. Kathryn Calhoun, MD May 9, 2012. Case. 32 yo G2P1001 LMP 10 wks ago 8 wga New Ob visit scheduled for next week Spotting, BLQ pain Diagnosis?. Case. Diagnosis: PUL with bleeding Differential Intrauterine pregnancy

hakan
Télécharger la présentation

Pregnancy of Unknown Location “PUL”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Pregnancy of Unknown Location “PUL” Kathryn Calhoun, MD May 9, 2012

  2. Case • 32 yo G2P1001 • LMP 10 wks ago • 8 wga • New Ob visit scheduled for next week • Spotting, BLQ pain • Diagnosis?

  3. Case • Diagnosis: PUL with bleeding • Differential • Intrauterine pregnancy • “threatened abortion”, SABs 60% conceptions • Consider torsion, hemorrhagic CL • Ectopic pregnancy (2% conceptions) • Heterotopic pregnancy (1/4000 non-ART)

  4. What do you want to do? • History • Physical • Labs • Ultrasound

  5. History • PMH/PSH/Ob/Gyn/Social • Bleeding history • Amount? Duration? Passage of tissue? • Pain history • Focus on risk factors for ectopic • Major • Minor

  6. Risk factors for ectopic Major Risk Factors: • Previous Ectopic • 10% if one, 25% if two • Abnormal tubes • PID, surgery

  7. Risk factors for ectopic Minor Risk Factors: • Smoking cigarettes • Age > 35 • # lifetime sexual partners • IUD in place • Infertility • IVF (heterotopic 1/4000  1/100) • 50% have no risk factors

  8. Case • PMH: hypothyroidism • PSH: FTC/S – FTP • Gyn: No STIs, no abnlPaps, 3 lifetime partners, currently monogamous with husband – using withdrawal method • SH: Married, RN – labor floor, no T/D, social EtOH

  9. What do you want to do? • History • Physical • Labs • Ultrasound

  10. Physical • VS • UPT • Abdomen • Pelvic • Evaluate for acute abd but do not rupture ectopic! • Cervix open? • Blood or tissue present? • Float tissue or send to pathology

  11. Case • VS: 97.9, 120/70, P 101, RR 18, 99% RA • 5’8” 140lb • UPT: positive • Abd: soft, NT • Pelvic: NEFG, brown mucus, cervix closed • Assessment? • No acute abdomen • Does not need STAT OR

  12. What do you want to do? • History • Physical • Labs • Ultrasound

  13. Labs • Blood type • CBC • Quantitative HCG

  14. Case • O neg • Hgb 12 • HCG 4500

  15. What do you want to do? • History • Physical • Labs • Ultrasound

  16. Ultrasound • When is this helpful? • What should we see? • Quant 4500 • TV or Abdominal?

  17. Ultrasound expectations • By gestational age • 4-5 wga: GS, DD sign - 5.5: YS • 6 wga: FP - 6.2-6.5: +FHTs • By quantitative HCG level • 1500-3000: evidence of IUP (unless twins!) • By size of US structures • GS 8mm (TV) or 20mm (TA): should see YS • GS 16mm (TV) or 25mm (TA): should see FP • FP 5mm: should see FHTs

  18. Double Decidual Sign 2 layers of echogenicdecidua separated by a thin echolucent line. Not present at the site of placental development.

  19. A sac in the uterus Developing GS Endometrial cyst in basalis

  20. Measuring the GS: Mean Sac Diameter 3 dimensions: Length, Height, Width Measure from fluid/tissue interface to fluid/tissue interface

  21. Developing yolk sac When MSD 8mm (TV) or 20mm (TA) If no YS, then “empty sac”

  22. Fetal pole/embryo appears MSD 16mm (TV) or 25mm (TA) If not, “anembryonic gestation” or “blighted ovum” Measure fetal pole in Crown-Rump length (CRL) Needs FHT by CRL 5mm or “failed IUP”

  23. How do you manage a failed IUP?

  24. How do you manage a failed IUP? • Expectant • Medical (See Miso handout) • Cytotec 800mcg PV • Repeat 48hrs if no result • Surgical • Curettage in office or OR • Advantages: usually definitive • Disadvantages: Instrumentation, anesthesia

  25. Case: TV Ultrasound Thickened hyperechoic lining No sign of IUP

  26. So … now what?? • PUL, bleeding, BLQ pain • Quant 4500 • Thickened ES but no clear IUP

  27. Let’s look at the Adnexae!

  28. Adnexae Right Ovary Left Ovary

  29. Diagnosis?

  30. So … now what?? • DDX: • Hemorrhagic right CL with failing IUP • Right ovarian ectopic • Heterotopic • Plan: • Admit and observe? • OR?

  31. The CL can deceive … Hemorrhagic

  32. A recent non-topic at UNC ADJACENT MASS OVARY • 37 yo G3P2002 with cramping, VB • CBC WNL • HCG 9499 • ES 23mm

  33. Upon Laparoscopic Entry

  34. Laparoscopic Images Right ovary with CLC Normal right tube and mesosalpinx

  35. If you go to the OR … • You may be obligated to go to OR in patient with PUL, pain and adnexal mass • Surgical plan? • Outright LSC • D+C with frozen for POC • If negative, proceed with diagnostic LSC • If positive, check quant 24 hrs • Should fall 15-20%+ • What if it doesn’t fall? • Repeat imaging • Medical vs Surgical vs Expectant mgt as appropriate

  36. What if her imaging had looked like this?

  37. Diagnosis?

  38. Management of Ectopic Pregnancy • Surgical • Medical • Expectant • If HCG < 200 and declining

  39. Surgical Management of Ectopic • Only option if patient HD unstable • Stable patient • LSC with salpingostomy • Requires post-op quants +/- MTX • LSC salpingectomy

  40. What to do with the tubes?

  41. Medical Management of Ectopic • Methotrexate (MTX) • 1980s • Folic acid antagonist (chemotherapeutic) • Attacks actively proliferating cells • Rapidly cleared by kidneys • ~ 90% success rates in properly-selected patients

  42. Who can get MTX?

  43. MTX Contraindications ABSOLUTE RELATIVE Pain Ectopic > 3cm Ectopic with FHTs Blood in pelvis Location? HCG > 5000 May just decrease efficacy or increase chance of multi-dose • Unstable/rupturing • Non-compliant/No access • Coexistent IUP • Allergic to MTX • Renal, hepatic, pulmonary, hematologic or peptic ulcer disease • Immunodeficiency • Alcoholism • Breast-feeding

  44. MTX side effects • Pain • Bleeding • Stomatitis • GI upset • NSAIDs can exacerbate • Rarely renal/hepatic issues in women with normal baseline labs More frequent in successful treatments

  45. MTX: How do you give it? • If truly still a PUL, would consider evacuating uterus to prove ectopic before labeling patient and giving MTX

  46. MTX: How do you give it? • Verify normal baseline safety labs • CBC, Creatinine, LFTs • Dose: 50 mg/m2 (calculate BSA), IM shot • Stop PNV/folate, avoid sun exposure, avoid NSAIDs, pelvic rest until HCG <5 • Single dose vs. Two-dose vs. Multi-dose • Named for the intended # of doses

  47. Single dose MTX • Day 1: HCG, safety labs, MTX#1 • Day 4: HCG • Day 7: HCG, safety labs • Needs to drop by 15% from Day 4 or re-dose and recheck for 15% drop on Day 11 (2 Dose Protocol) • If it drops ≥ 15%, follow HCG Q week to <5

  48. Multi dose protocol • Add leucovorin 0.1mg/kg (LCV, folinic acid) to rescue normal cells • Day 1: HCG, safety labs, MTX#1 • Day 2: HCG, LCV #1 • Day 3: MTX #2 • Day 4: HCG, LCV #2 • Repeat sequence for up to 4 doses • When HCG drops by 15%, check weekly

  49. What if medical management fails? • Re-image • If imaging negative, evacuate uterus if not already done • Consider diagnostic LSC

More Related