1000-2000 5 ьшò

treatment of GERD.

Insufficient evidence for routine use of botulinum toxin

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Complete or partial esophageal obstruction associated with malnutrition or dehydration

Need for enteral feeding

Outpatient if patient is able to maintain nutrition and has little risk of complications

Hospitalization with total or near-total obstruction of esophageal lumen

Hospitalization may be needed for endoscopy and/or esophageal dilatation and is generally indicated for diagnostic or therapeutic surgical procedures.

IV fluids for dehydrated, hypovolemic patients, and patients with impaired consciousness

Discharge when tolerating adequate diet without nausea/pain

ONGOING CARE

DIET

See “General Prevention.”

PATIENT EDUCATION

Dietary modification; no eating at bedtime; remaining upright after eating; smoking cessation

PROGNOSIS

Vary with specific diagnosis

COMPLICATIONS

Oropharyngeal: pneumonia, lung abscess, aspiration, airway obstruction

Malnutrition and dehydration

REFERENCES

1.American College of Radiology. ACR appropriateness criteria for dysphagia. https://www.guidelinecentral.com/summaries/acr-appropriateness-criteria-

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dysphagia/. Accessed October 4, 2017.

2.Al-Hussaini A, Latif EH, Singh V. 12-minute consultation: an evidence-based approach to the management of dysphagia. Clin Otolaryngol. 2013;38(3):237–243.

3.Pasha SF, Acosta RD, Chandrasekhara V, et al; and ASGE Standards of Practice Committee. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191–201.

4.Dai Y, Li C, Xie Y, et al. Interventions for dysphagia in oesophageal cancer.

Cochrane Database Syst Rev. 2014;(10):CD005048.

ADDITIONALREADING

Jones K, Pitceathly RD, Rose MR, et al. Interventions for dysphagia in longterm, progressive muscle disease. Cochrane Database Syst Rev. 2016; (2):CD004303.

Malagelada JR, Bazzoli F, Boeckxstaens G, et al. World Gastroenterology Organisation global guidelines: dysphagia—global guidelines and cascades update September 2014. J Clin Gastroenterol. 2015;49(5):370–378.

Perry A, Lee S, Cotton S, et al. Therapeutic exercises for affecting posttreatment swallowing in people treated for advanced-stage head and neck cancers. Cochrane Database Syst Rev. 2016;(8):CD011112.

CODES

ICD10

CLINICALPEARLS

Dysphagia is an alarm symptom that warrants prompt evaluation to define the exact cause and initiate appropriate therapy.

Patients with oropharyngeal dysphagia usually report feeling an obstruction in the neck and point to this area when asked to identify the site of their symptoms.

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ECTOPIC PREGNANCY

Jessica Johnson, MD, MPH

BASICS

DESCRIPTION

Ectopic: pregnancy implanted outside the uterine cavity. Subtypes include:

Tubal: pregnancy implanted in any portion of the fallopian tube

Abdominal: pregnancy implanted intra-abdominally, most commonly after tubal abortion or rupture of tubal ectopic pregnancy

Heterotopic: pregnancy implanted intrauterine and a separate pregnancy implanted outside uterine cavity

Ovarian: implantation of pregnancy in ovarian tissue

Cervical: implantation of pregnancy in cervix

Intraligamentary: implantation of pregnancy within the broad ligament

EPIDEMIOLOGY

Incidence

108,800 cases in 1992 in the United States, according to CDC census (most recent data available), meaning that 1.5–2.0% of all pregnancies were ectopic. The true incidence is difficult to estimate.

In the United States, ectopic pregnancy is the leading cause of 1st trimester maternal deaths and accounts for 6% of all pregnancy-related deaths.

Heterotopic pregnancy, although rare (1:30,000), occurs with greater frequency in women undergoing in vitro fertilization (IVF) (1/1,000).

Increasing incidence of nontubal, and particularly cesarean scar ectopic pregnancies, due in part to more cesarean sections and more IVF

Prevalence

~33% recurrence rate if prior ectopic pregnancy

ETIOLOGYAND PATHOPHYSIOLOGY

95–97% of ectopic pregnancies occur in the fallopian tube, of which, 55–80% in the ampulla, 12–25% in the isthmus, and 5–17% in the fimbria.

One risk factor for a tubal pregnancy is impaired movement of the fertilized

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ovum to the uterine cavity due to dysfunction of the tubal cilia, scarring, or narrowing of the tubal lumen.

Other locations are rare but may occur from reimplantation of an aborted tubal pregnancy or from uterine structural abnormalities (mainly cervical pregnancy).

RISK FACTORS

History of pelvic inflammatory disease (PID), endometritis, or current gonorrhea/chlamydia infection

Previous ectopic pregnancy

History of tubal surgery (~33% of pregnancies after tubal ligation will be ectopic.)

Pelvic adhesive disease (infection or prior surgery)

Use of an intrauterine device (IUD): Overall chance of any pregnancy with an IUD is low; however, there is an increased likelihood of ectopic location if pregnancy occurs. IUDs reduce absolute risk of ectopic pregnancy.

Use of assisted reproductive technologies

Maternal diethylstilbestrol (DES) exposure in utero (DES was last used in 1972.)

Tobacco use

Patients with disorders that affect ciliary motility may be at increased risk (e.g., endometriosis, Kartagener).

GENERALPREVENTION

Reliable contraception or abstinence

Screening for and treatment of STIs (i.e., gonorrhea, chlamydia) that can cause PID and tubal scarring

DIAGNOSIS

HISTORY

In >50% of presenting cases, patients have sudden-onset abdominal pain coupled with cessation of/or irregular menses and acute vaginal bleeding (the classic triad). Other common symptoms include nausea and/or vomiting, vaginal bleeding, and pain referred to the shoulder (from hemoperitoneum).

PHYSICALEXAM

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Abdominal tenderness ± rebound tenderness

Vaginal bleeding

Palpable mass on pelvic exam (adnexal or cul-de-sac fullness)

Cervical motion tenderness

In cervical cases, an hourglass-shaped cervix might be noted.

In cases of rupture and significant intraperitoneal bleeding, signs of shock such as pallor, tachycardia, and hypotension may be present.

DIFFERENTIALDIAGNOSIS

Missed, threatened, inevitable, or completed abortion

Gestational trophoblastic neoplasia (“molar pregnancy”)

Appendicitis

Salpingitis, PID

Ruptured corpus luteum or hemorrhagic cyst

Ovarian tumor, benign or malignant

Ovarian torsion

Cervical polyp, cancer, trauma, or cervicitis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Check CBC and ABO type and antibody screen. Transvaginal US (TVUS) is the gold standard for diagnosis:

–Failure to visualize a normal intrauterine gestational sac when serum human chorionic gonadotropin (hCG) is above the discriminatory level (>1,500 to 2,000 IU/L) suggests an abnormal pregnancy of unknown location (PUL).

–An hCG level of 3,500 IU/Lis associated with a 99% probability of detecting a normal intrauterine gestational sac in clinical practice (1).

–These values are not validated for multiple gestations.

If TVUS unavailable or inconclusive for intrauterine pregnancy (IUP), check hCG: Serial quantitative serum levels normally increase by at least 53% every 48 hours: Abnormal rise (<35%) should prompt workup for gestational abnormalities. Clinical impression of acute abdomen/intraperitoneal bleeding concurrent with a positive hCG level is indicative of ectopic pregnancy until proven otherwise.

MRI may also be useful but costly and rarely used if TVUS is available; benefits particularly for abdominal or cesarean scar pregnancy

Follow-Up Tests & Special Considerations

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Serum progesterone level: >20 mg/mL associated with lower risk of ectopic pregnancy. In women with pain and/or bleeding who have an inconclusive US, serum progesterone level <3.2 ng/mLruled out a viable pregnancy in 99.2% of women (2); may provide additional data for PUL but does not predict ectopic pregnancy (3)[B]

Under investigation: evaluation of serum progesterone levels in conjunction with vascular endothelial growth factor, inhibin A, and activin Ausing an algorithm. This diagnosed patients with ectopic pregnancy with 99% accuracy.

Diagnostic Procedures/Other

In the setting of an undesired pregnancy, sampling of the uterine cavity with endometrial biopsy or D&C can identify the presence/absence of intrauterine chorionic villi. When an IUPhas been evacuated by curettage, hCG levels should drop by 50% within 48 hours.

Historically, culdocentesis was performed to confirm suspected hemoperitoneum prior to surgical management. Currently, TVUS quantification of pelvic fluid is sufficient.

Test Interpretation

Products of conception (POC; especially chorionic villi) outside the uterine cavity

TREATMENT

MEDICATION

Methotrexate (MTX): treatment for unruptured tubal pregnancy or for remaining POCs after laparoscopic salpingostomy. MTX inhibits DNA synthesis via folic acid antagonism by inactivating dihydrofolate reductase.

Because TVUS often shows PUL, before treating with MTX, you should confirm suspected US findings with 2 hCG levels drawn 48 hours apart. Rise <35% is consistent with nonviable pregnancy.

Most effective when pregnancy is <3 cm diameter, hCG <5,000 mIU/mL, and no fetal heart movement is seen. Success rate is 88% if hCG <1,000 mIU/mL, 71% if hCG 1,000 to 2,000 mIU/mL, 38% if 2,000 to 5,000 mIU/mL:

–Three main dosage regimens exist (4):

Single: IM MTX 50 mg/m2 of body surface area (BSA); may repeat once

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(preferred method) if <15% decline in hCG between day 4 and 7. Follow hCG weekly.

Double dose: MTX 50 mg/m2 of BSAonce and then repeated on day 4; if <15% decline in hCG between day 4 and 7, may repeat 3rd dose on day 7. Repeat hCG as needed on day 11 and 14 until decreases >15% in the interval, then weekly. If not dropping by day 14, refer for surgical management.

Multidose: MTX 1 mg/kg IM/IV every other day, with leucovorin 0.1 mg/kg IM in between. Maximum 4 doses until hCG drop below 15%; course may be repeated 7 days after last dose if necessary.

–Contraindications:

Hemodynamic instability or any evidence of rupture

Moderate to severe anemia

Severe hepatic or renal dysfunction

Immunodeficiency

–Relative contraindications Fetal heart rate seen

Large gestational sac (>3 cm, less effective)

Noncompliance or limited access to hospital or transportation

High hCG count >5,000 mIU/mL

Precautions: immunologic, hematologic, renal, GI, hepatic, and pulmonary disease, or interacting medications

Pretreatment testing: serum hCG, CBC, liver and renal function tests, blood type and screen

Patient counseling: During therapy, refrain from use of alcohol, aspirin, NSAIDs, and folate supplements (decreases efficacy of MTX); avoid excessive sun exposure due to risk of sensitivity.

–Adherence to scheduled follow-up appointments is critical.

–Increased abdominal pain may occur during treatment; however, severe pain, nausea, vomiting, bleeding, dizziness, or light-headedness may indicate treatment failure and require urgent evaluation.

Rupture of ectopic pregnancy during MTX treatment ranges from 7% to 14%.

Side effects include stomatitis; conjunctivitis; abdominal cramping; and rarely neutropenia, pneumonitis, or alopecia (5).

Systemic MTX may be offered in some kinds of nontubal ectopic pregnancies, but data is limited.

ISSUES FOR REFERRAL

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Consider gynecologic consultation if not experienced in medical management.

Refer to a gynecologist for surgical care.

ADDITIONALTHERAPIES

Physician or patient may elect for surgical treatment as primary method and then postop hCG should guide need for supplemental MTX.

After evidence of medical failure or tubal rupture, surgery is necessary.

Treatment of cervical, ovarian, abdominal, or other ectopic pregnancy is complicated and requires immediate specialist referral.

Follow all patients treated medically to an hCG of 0 to ensure that there is no need for surgical intervention.

Offer anti-D Rh prophylaxis at a dose of 50 µg to all Rh-negative women who have a surgical procedure to manage an ectopic pregnancy or if there has been significant bleeding or abdominal pain.

Expectant management of ectopic (confirmed on TVUS) should be offered to women who are clinically stable and have decreasing hCG level initially <1,500 mIU/mL (3)[B].

Expectant management to allow for spontaneous resolution of PULis acceptable in asymptomatic patients with no evidence of rupture or hemodynamic instability coupled with an appropriately low hCG and no extrauterine mass suggestive of ectopic. Ruptured tubal pregnancies may occur even with extremely low hCG levels (<100 mIU/mL) (6).

With expectant management of PUL, repeat TVUS weekly (or when hCG above discriminatory zone) until location is confirmed or clinical picture is unstable.

SURGERY/OTHER PROCEDURES

Indications include ruptured ectopic pregnancy, inability to comply with medical follow-up, previous tubal ligation, known tubal disease, current heterotopic pregnancy, desire for permanent sterilization at time of diagnosis.

Laparoscopy is the first-line surgical management (3)[A].

Salpingectomy (tubal removal) is preferred and is indicated for uncontrolled bleeding, recurrent ectopic pregnancy, severely damaged tube, large gestational sac, or patient’s desire for sterilization (3)[B].

Salpingostomy (preservation of tube) is considered in patients who wish to maintain fertility particularly if contralateral tube is damaged/absent (3)[C]:

–No difference in recurrence rate compared to salpingectomy

–Persistent trophoblastic tissue with salpingostomy remains in the fallopian

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tube in 4–15% of cases; will need to follow weekly hCG

Use of US-guided intra-amniotic injection with MTX and/or potassium chloride is experimental at this time.

Surgical treatment is first line for cesarean and cornual pregnancies.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Fails criteria for MTX management, suspicion of rupture, orthostatic, shock, and severe abdominal pain requiring IV narcotics

Inpatient observation in the setting of an uncertain diagnosis, particularly with an unreliable patient, may be appropriate.

Surgical emergency

–Two IV access lines should be placed immediately if suspicion of rupture; aggressive resuscitation as needed

–Blood product transfusion if necessary en route to OR

–In cases of shock, pressors and cardiac support may be necessary.

IV fluids

–Unnecessary for a stable ectopic pregnancy being medically treated

–Critical for a surgical patient who is bleeding

Strict input/output, hourly vitals, orthostatics if mobile, frequent abdominal exams, serial hematocrit, pad counts if heavy vaginal bleeding

Discharge criteria: afebrile, abdominal pain resolving or resolved, diagnosis established, surgical treatment, and recovery is complete

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Serial serum quantitative hCG until level drops to zero:

–After MTX administration, a strict monitoring protocol should be followed (5).

–Following salpingostomy, weekly levels are appropriate.

–Following salpingectomy, further follow-up may be unnecessary.

Pelvic US for persistent or recurrent masses

Pain control: brief course of narcotics usually necessary with medical or surgical management

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Liver and renal function tests weekly following MTX administration if repeat dosing is required

Delay of subsequent pregnancy for at least 3 months after treatment with MTX due to teratogenicity (folate deficiency) (3)[C]

DIET

During treatment, avoid alcohol and foods and vitamins high in folate (leafy greens, liver, edamame) due to interaction with MTX efficacy.

Maintain excellent hydration.

PATIENT EDUCATION

Signs and symptoms of ectopic pregnancy should be reviewed.

Patients should be encouraged to plan subsequent pregnancies and seek early medical care on discovery of future pregnancies.

PROGNOSIS

Chronic ectopic pregnancies are rare and treated with surgical removal of the fallopian tube.

Future fertility depends on fertility prior to ectopic pregnancy and degree of tubal compromise. In women with normal fertility, treatment options have no differences in future fertility rates. In women with subfertility, expectant or medical treatments confer better future fertility (3)[C].

~66% of women with a history of ectopic pregnancy will have a future IUPif they are able to conceive.

If infertility persists beyond 12 months, the fallopian tubes should be evaluated.

COMPLICATIONS

Hemorrhage and hypovolemic shock

Persistent trophoblastic tissue after medical or surgical management

Infection

Infertility

Blood transfusions with associated infections/transfusion reaction

Disseminated intravascular coagulation in the setting of massive hemorrhage

REFERENCES

1.Connolly A, Ryan DH, Stuebe AM, et al. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol.

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