Kavitha, P (2013) Study the outcome of medically (Methotrexate) managed cases of unruptured ectopic tubal pregnancies. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION: The first recorded case of ectopic pregnancy is that of Albucasis in the 11th Century. The modern management of ectopic pregnancy is one of medicine’s greatest success stories. The term Ectopic is derived from the Greek word “Ek and to-pos”, meaning “out of place or displaced”. Ectopic pregnancy is defined as the implantation of fertilized ovum or blastocyst anywhere other than in a normal uterine cavity. This includes tubal pregnancies and non-tubal pregnancies involving the ovary, cornual region of the uterus, rudimentary uterine horn, the abdominal cavity, and in the cervix. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death. AIM OF STUDY: 1. To study the outcome of medically managed cases of unruptured tubal ectopic pregnancies using intramuscular methotrexate. 2. To study the association of outcome with the following parameters: a) Initial β–hCG levels, b) Adnexal mass size, c) Period of amenorrhea, d) Presence or absence of cardiac activity. MATERIALS AND METHODS: All patients admitted to Institute of Obstetrics and Gynecology, with diagnosis of unruptured ectopic pregnancy managed medically between August 2011 and July 2012 were included in the study. The diagnosis of tubal pregnancy was made using both Transvaginal Sonography (TVS) and measurement of β-hCG level. Ectopic pregnancy was diagnosed when adnexal mass or extra uterine tubal gestational sac without intrauterine gestation was observed with TVS and when patients had inappropriately rising β-hCG levels. Patients who were hemodynamically unstable and who refused medical treatment with MTX and close follow-up were treated surgically. The patients who were managed medically with methotrexate were categorized into 5 groups for follow up based on initial β-hCG levels. (<2500) mIU/ml, (2500-5000) m IU/ml, and (7500-10000) m IU/ml. Patients with very low β-hCG levels (<200 m IU/ml) were managed expectantly. Single dose methotrexate regimen was followed for patients with β -hCG levels ranging from 200m IU/ml to 6984 m IU/ml. Multiple dose methotrexate regimen was followed for patients with β-hCG levels more than 7500 m IU/ml. Before treatment with methotrexate, patients were counseled about the benefits and risk of treatment, the expected course and duration of treatment, and the importance of follow-up. Blood grouping and typing was done for all the patients and Anti-D immunoglobulin (2501U or 50 micrograms) administered to all Rh Negative mothers. All patients gave their informed consent before beginning the treatment. Inclusion Criteria: • Patients who came with amenorrhea , abdominal pain, bleeding or spotting P/V and were diagnosed to have ectopic pregnancy after doing: 1. Urine Pregnancy Test, 2. Trans vaginal sonography, 3. Serum β-hCG Levels. • Hemodynamically stable patients without active bleeding or signs of hemoperitoneum. • Patients desiring future fertility, • Patients willing for follow up care, • No contraindication to MTX therapy. Exclusion Criteria: • Hemoperitoneum or hemodynamically unstable patients. • Contraindication to MTX therapy. 1. Breastfeeding, 2. Overt evidence of immunodeficiency, 3. Alcoholism /other chronic liver disease, 4. Pre existing blood dyscrasias, 5. Known sensitivity to methotrexate, 6. Active pulmonary disease, 7. Peptic ulcer disease, 8. Any chronic renal disorder. SUMMARY: 1. 39 cases of unruptured ectopic pregnancy which were managed medically with methotrexate were studied during the period of August 2011 to July 2012. 2. Maximum incidence of unruptured ectopic pregnancy was found amongst the age group of 20 to 29 years. 3. Commonest risk factor for ectopic pregnancy found in the study was Medical Termination of Pregnancy (17.9%), followed by previous LSCS being 12.8%. 4. 13% of cases had β-hCG levels <200 m IU/ml, 46.8% of cases of unruptured ectopic pregnancies had their initial β-hCG levels between 200-2500 m IU/ml, 41.2 % of cases had β-hCG levels between 2500-10,000 m IU/ml. 5. 56.4% of cases had adnexal mass size measuring between 2-3cms, 41% of cases presented with adnexal mass size <2cms, where as 59% of cases had initial adnexal mass size >2cms. 6. Of the 39 patients studied, 28.2% patients had amenorrhea <42 days, 56.4% had amenorrhea between 43-56 days, and 15.4% had amenorrhea more than 57 days. CONCLUSION: 1. Complete resolution was seen in all cases of single dose methotrexate regimen whose mean initial β-hCG was 2683 mIU/ml, adnexal mass<2cms and amenorrhea <42days. 2. Statistically significant association was seen between the initial β-hCG levels and with outcome of treatment. No statistical significance was found between adnexal mass size at presentation, period of amenorrhea and outcome of treatment in single dose regimen. 3. In cases managed with multiple dose methotrexate regimen, complete resolution was seen in those having mean initial β-Hcg of 7688.4 mIU/ml and adnexal mass size <2cms. 4. No statistically significant association was found between adnexal mass and outcome of treatment in multiple dose regimen.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Methotrexate ; unruptured ectopic tubal pregnancies. |
| Subjects: | MEDICAL > Obstetrics and Gynaecology |
| Depositing User: | Punitha K |
| Date Deposited: | 17 Jun 2018 01:23 |
| Last Modified: | 17 Jun 2018 02:12 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/8519 |
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