Ectopic Pregnancy: Management

00:01 So what are our steps here? So for an unstable patient take care of your ABCs, your airway, your breathing, your circulation.

00:08 Make sure the patient has good IV access.

00:11 Administer IV fluids.

00:13 If the patient has significant blood loss or is unstable go ahead and transfuse blood.

00:18 This is a situation where you may need to use uncross match blood, so O negative blood.

00:23 If the patient has RH negative blood type.

00:27 So if their blood type is A negative, O negative, B negative which ever.

00:31 You wanna administer RhoGam, and that’s gonna prevent from having complications either later in that pregnancy or with future pregnancies.

00:39 And then the options are surgery versus medical management.

00:44 So surgical management generally done by laparoscopy more commonly than laparotomy.

00:52 Laparoscopy is when you use cameras to take a look in the abdomen, done through smaller scars and smaller openings.

00:59 Laparotomy is when you make a large midline incision and go in and do the procedure.

01:06 Also to consider salpingostomy which is when the pregnancy is removed from the fallopian tube is preferred over salpingtectomy.

01:14 Salpingtectomy is when the fallopian tube itself is removed.

01:19 And it’s important to remember that transvaginal ultrasound will lead to earlier diagnosis and less operative interventions for these patients.

01:28 Now, medical management is another option.

01:32 And this is a great option for people who don’t want surgery or you know, who are otherwise stable.

01:39 Now, medical management takes place with methotrexate.

01:42 And what methotrexate does is it creates a medical abortion for the patient.

01:46 It has a very good success rate.

01:50 Uppers of 80%, so 85-93% success rate.

01:54 So what that means is that, a good majority of patients who have an ectopic pregnancy who are treated this way, will do okay.

02:01 They will abort the pregnancy and the pregnancy won’t rupture.

02:05 Now if you’re doing this, you need to make sure you follow your hCG levels to zero.

02:09 So you need to make sure that that level is decreasing and that the patient understand what to return to the Emergency Department for.

02:16 Because between 7 and 15% of these patients this treatment won’t work.

02:21 And what happens when it doesn’t work? When it doesn’t work, that pregnancy continues to grow.

02:27 And when the pregnancy continuous to grow the patient may develop a ruptured ectopic pregnancy.

02:32 So definitely you have to make sure that you selected the right patient for this treatment.

02:38 When should we use it? We can use it for clinically stable patient.

02:43 For patients who are hemodynamically okay.

02:47 They have a normal blood pressure.

02:48 They have a normal heart rate.

02:50 For a mass or pregnancy sac of less than 3.5 cm.

02:56 There shouldn’t be any fetal cardiac activity.

03:00 So if you see any kind of fetal cardiac activity, methotrexate is not your drug of choice.

03:05 And also if there’s no evidence of rupture.

03:08 So you need to make sure you check up all these boxes.

03:10 I include one other thing here that I need to make sure that my patient is reliable and that they understand what to come back to the Emergency Department for.

03:18 This isn’t necessarily a great option for someone who’s unreliable.

03:22 For patient who you think will not return to the Emergency Department, if they get a certain symptoms.

03:27 For someone who you know will ignore their symptoms for a period of time.

03:32 You wanna make sure that you self-select, or that you select the right people to get this medication.

03:38 For those patients that have that indeterminant ultrasound.

03:42 So the ultrasound doesn’t tell you that there is an ectopic pregnancy but it also doesn’t tell you that there’s something in the uterus.

03:48 For those patients you can check serial hCG levels.

03:53 Now, those levels in a normal pregnancy should double every 1 and a half to 3 days approximately.

04:01 So what you would wanna see is you wanna see if those numbers are doubling appropriately, if they’re staying the same or if they’re going down.

04:09 You also wanna advise your patient to get a repeat ultrasound.

04:13 For the most part that repeat ultrasound is recommended when the patient is in the good zone of the hCG level where you would expect to see something.

04:22 So for example if you obtain the first ultrasound when the HCG level is 500, you would wanna repeat that ultrasound when the HCG level is over about 2000.

04:32 Because that’s when you reliably expect to see something on the ultrasound.

04:37 You also wanna give your patient strict return precautions.

04:41 If they go home, if their pain changes in anyway, their bleeding changes.

04:45 The pain becomes more severe.

04:47 They feel light headed.

04:48 Tell them to come right back to the Emergency Department.

04:52 Because that may indicate that there is an ectopic pregnancy that just wasn't recognized initially.

04:57 So the conclusions here, ectopic pregnancy has the high maternal mortality.

05:02 Make sure that you’re thinking about it.

05:05 History and physical exam and lab findings can have poor sensitivity.

05:10 Serum hCG levels can help guide your treatment and your disposition.

05:15 But levels of less than 1000 can become an ectopic pregnancy.

05:19 Ultrasounds that are indeterminant will require follow-up for patients.

05:24 And management can either be surgical or medical depending on the size of the ectopic and whether or not there has been rupture.