Diagnosis
Incidence is 11/1000 Pregnancies
USS-TVS>TAS
99%, 98%
Can see:
Location/viability/heterotopic/FF
Features
- Sac with embryo,
- inhomogeneous mass
seperate from ovary, - sac with
hyperechogenic ring - Pseudo sac
- Eclipse,
- middle,
- single border,
- no doppler
true IU Sac - Round,
- eccentric in decidua,
- Intra/double decidual sign,
- doppler HCG
Single: useful to select mode of MX/not for location
- Serial :more useful for follow up.
- Rate of rise less useful than USS
- Repeat 48 hrs
- Discriminatory zone –
1000 TVS, 6500 TAS
Progesterone
Short T ½ 2 hrs
Single measure
- <20ng/l more likely regress ( suitable for conservative)
- >60 more likely progress
Laparoscopy
Previously gold standard, Now limited role, look for tubal swelling.
3% False negative.
Options-
conservative ,medical, surgical, no Fertility reducing factors all equal pregnancy,
patency rates, recurrence if no RF for SF
Factors to be considered fertility, preference, CI,USS size, beta HCG, willing to follow up.
Conservative
- <1500 decreesing ( suggestive if progesterone <20nmol/L)
- <30mm
- Follow up+
- Success up to 70% in selected
- Advantages Natural No MTX SE ,No Sx
- Disadvatages
- Long follow up
- May need later
intervention/rupture - Anxiety
Medical
- MTX
- <1500
- <35mm
- Follow up
- Exclude CI- Allergy, liver, renal, BM problem, PUD, breast feeding ,IUP, Insability
- advantages
- Cost effective ( single Corse)
- No Sx SE
- For RF for SF + may improve pregnancy rates
- Disadvantages
- Started on second visitto exclude IUP
- Long follow up
- May need later surgery
- SE MTX- conjunctivitis,
Peptic ulcer, LFT, RFT,
BM, pulmonary fibrosis teratogenicity, - wait 3 months for next pregnancy
Sx or MTX
- HCG 1500-5000
Surgery
- laparoscopy- (short stay, less adhesions, less pain, quick recover)
- >5000
- >35mm
- Heart Beat
- Symptomatic patients
- instability
- Salpingotomy- if RF for
SF present(more pregnancy rate), - Salpingectomy-if no Subfertility
Risk Factors present( no need of
HCG follow up), or Hydrosalpinx and IVF planned - Rhogum prophylaxis if Rh negative
- Advantages No need follow up- in salpingectomy
- Histological diagnosis possible
- Cost effective than multiple doses of MTX
- No need to wait for pregnancy
- Disadvantages
- Surgical /Anesthetic risk
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