Ectopic Pregnancy (Ectopic Pregnancy) (Part Two)

Diagnosis

1. Bhcg in maternal serum

   In a normal pregnancy, Bhcg doubles every 48-72 hours until it reaches values of 10,000-20,000. In an ectopic pregnancy, Bhcg usually increases less. Thus, the level of Bhcg in an ectopic pregnancy is at lower values. A single dose is not used, but several doses measured in series to differentiate a normal pregnancy from an ectopic one. It is used to monitor the resolution of the ectopic pregnancy when medical therapy begins.

2. The relationship between ultrasound and Bhcg

   In a normal pregnancy, we have Bhcg values of 1500-1800 mIu/ml and assessment of the gestational sac with transvaginal ultrasound in a pregnancy with one fetus and in multiple pregnancies we have Bhcg values above 2300 mIu/ml. Bhcg values vary from 6000-6500 mIu/ml when the gestational sac is distinguished with transabdominal ultrasound. The absence of intrauterine pregnancy in transvaginal or transabdominal ultrasound with Bhcg values at the level of the discriminatory zone suggests an ectopic pregnancy or previous miscarriage.

3. Ultrasound

   It is one of the most important examinations for diagnosis.

   The presence of an intrauterine sac, with or without fetal heart rate, excludes an ectopic pregnancy. Transvaginal ultrasound assesses the pregnancy 24 days after ovulation or 38 days from the last menstruation (approximately 1 week earlier than transabdominal ultrasound). In ultrasound, an empty uterus and a Bhcg level above normal suggest an ectopic pregnancy until proven otherwise.

4. Laparoscopy

   Laparoscopy misses 4% of cases. It is indicated in a patient with pain and hemodynamic instability.

Complications

Arise from lack of diagnosis, late diagnosis, or improper treatment.

1. Rupture of the uterus and fallopian tubes.
2. Massive hemorrhage, shock, AKI, death.
3. Surgical treatment leads to hemorrhage, infections, damage to surrounding organs such as intestines, urinary bladder, ureter, large vessels.
4. Infertility
5. Secondary complications from anesthesia.

Management

Options include:
• expectant management
• methotrexate
• surgery

1. Expectant management

   Indicated in an asymptomatic patient, who shows no signs of rupture or hemodynamic instability and the patient must have low Bhcg values.

2. Methotrexate

   Standard treatment in a non-ruptured ectopic pregnancy. A single dose im is used in a patient, stable hemodynamically, with persistent or not strong abdominal pain, when follow-up is possible multiple times, when kidney and liver function is normal.

   Contraindications of treatment with methotrexate include an intrauterine pregnancy, immunodeficiency, moderate to severe anemia, thrombocytopenia, leukopenia, medication hypersensitivity, gastric ulcer, pulmonary problems, renal and hepatic dysfunction, breastfeeding, and evidence of tubal rupture.

3. Surgical treatment

   Laparotomy is indicated in a hemodynamically unstable patient, cornual ectopic pregnancy, difficult laparoscopy.

Home Care

• Care for the incision after surgery (keep it clean, dry).
• Look for signs of infection if bleeding does not stop, pronounced and smelly bleeding from the drainage site, the site is warm to the touch, red, swollen.
• After surgery, expect some light vaginal bleeding or small blood clots. This occurs up to 6 weeks later.
• The patient should not lift heavy weights.
• Should drink plenty of fluids to prevent constipation.
• Pelvic rest (avoid sexual contact, use of tampons, and vaginal douching).
• Rest as much as possible in the first week and gradually increase physical activity according to individual tolerance.

Prevention
• Use a condom (condom) during sexual contact to prevent STIs and PID.
• Have regular visits to the gynecologist.
• Stop smoking.