Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_160_библиотеки_им_акад_М_И_Перельмана
.pdf
LOWER GENITAL TRACT INFECTIONS 43
• In the primary stage, an initial ulcer appears at the point of infection and is usually visible on the
vulva. In contrast to genital herpes, the ulcer is painless.
• The secondary stage follows 4 to 10 weeks after the primary infection and involves systemic
symptoms (e.g., fever, weight loss, hair loss, headache). Patients usually have a characteristic
maculopapular rash on the palms and soles of the feet.
• In the latent stage, patients have serologic proof of infection without symptoms of disease. These
patients are at risk for tertiary syphilis, which affects multiple organ systems: cardiovascular
system (e.g., aortitis), skin (e.g., chronic gummas), and central nervous system (e.g., dementia,
tabes dorsalis, Argyll Robertson pupil, seizures, meningitis).
Syphilis is diagnosed by visualization of the organism using dark-field microscopy or through
serologic testing with either the fluorescent-labeled Treponema antibody test (FTA-ABS) or Trepo-
nema pallidum particle agglutination assay (TPPA).
Screening is performed using nontreponemal tests, either the rapid plasma reagin (RPR) or the
Venereal Disease Research Laboratories (VDRL) test. If results of either of these tests are positive, a
confirmatory test is required. False-positive screening test results can be caused by some viral infec-
tions (e.g., varicella, measles) and other disease processes (e.g., tuberculosis [TB], lymphoma).
Treatment depends on the stage of the disease, a patient’s allergy status, and whether a patient
is pregnant. In general, intramuscular penicillin is the antibiotic of choice. Doxycycline, tetracycline, or
azithromycin may be considered as alternatives except in pregnancy. Physicians should be aware of the
Jarisch-Herxheimer reaction, which is caused by the release of inflammatory cytokines on death of the
bacteria. This reaction can cause fever, chills, rigors, hypotension, tachycardia, vasodilation, and myalgia.
15. What are the characteristics of Chlamydia infection?
Chlamydia infection is caused by C. trachomatis and produces mucopurulent discharge, although the
infection is often asymptomatic. C. trachomatis can be cultured, or the diagnosis made by identifying
Chlamydia mRNA with a genetic probe. Treatment is with doxycycline, azithromycin, or one of several
quinolones. Undiagnosed infection can cause infertility and chronic pelvic pain. Chlamydia can also
infect the upper genital tract and cause pelvic inflammatory disease (PID).
16. What causes genital herpes?
Herpes infection is caused by one of two herpes simplex viruses, HSV-1 and HSV-2. HSV-1 more commonly
causes perioral infection (“cold sores”), and HSV-2 is more commonly isolated in genital infections. As with
other herpes viruses (e.g., herpes zoster), infection with HSV is chronic. The virus becomes dormant after
the initial outbreak, but it can always reactivate and cause subsequent outbreaks.
17. How does genital herpes manifest?
Herpes typically causes small vesicular eruptions—which may or may not be clustered—that rapidly
progress to shallow, painful ulcers. Lesions can occur anywhere on the labia, vaginal epithelium,
cervix, or perineum. Inguinal adenopathy can be present, as well as vaginal discharge. However, the
most common complaint is pain. Systemic symptoms (e.g., fever and malaise) may also be present.
Although rare, urinary retention requiring bladder catheterization can result from involvement of the
sacral portions of the spinal cord. Asymptomatic infection is also possible; herpes antibodies can be
isolated from women with no known history of infection.
18. Does a difference exist between a primary and a recurrent herpes outbreak?
Yes. A primary herpes outbreak is typically more severe and longer in duration (12 to 21 days). Recur-
rent outbreaks generally manifest with relatively mild symptoms and last 2 to 5 days. The frequency
of recurrence is quite variable; some women experience only a single outbreak, and others may have
several recurrences each year.
19. When is genital herpes contagious?
The virus can be shed and transmitted at any time, during both symptomatic and asymptomatic
periods. Spread is through direct contact, although healed ulcers are no longer considered infectious.
Patients are also contagious in the days just before an outbreak. During this time, they may or may not
experience prodromal symptoms such as tingling or burning in the affected region.
20. How is genital herpes treated?
HSV infection cannot be cured, but the symptoms and duration of primary and recurrent outbreaks
can be reduced with antiviral agents. Several agents are effective and include acyclovir, valacyclovir,
and famciclovir. Initial treatment is for 7 to 10 days, and treatment for 2 to 5 days is indicated for
recurrences.
https://t.me/med1917
44 GENERAL GYNECOLOGY
21. Does HSV suppression have a role?
Suppression therapy with antivirals is effective in reducing the frequency of recurrences. The decision
to use suppressive therapy is up to the patient. In general, suppression is recommended for women
who have more than two or three outbreaks a year.
22. Does HSV infection have any other sequelae?
Primary HSV infection during pregnancy is potentially very serious. Transmission to the newborn can
occur if a woman has an active herpes outbreak or prodrome at the time of vaginal delivery. Although
the rate of neonatal infection is greatest for women experiencing an initial outbreak, it can occur even
during a secondary outbreak. For this reason, women with prodromal symptoms or active lesions at
the time of labor should be delivered by cesarean section. To prevent recurrences around the time
of delivery and avoid cesarean section, the American Congress of Obstetricians and Gynecologists
(ACOG) recommends that suppressive antiviral therapy be given in the last 4 weeks of pregnancy to all
women with a history of recurrent genital HSV.
Although rare, other potential sequelae include ocular infections (e.g., conjunctivitis or herpetic
keratoconjunctivitis with dendritic corneal ulcers), skin infections (e.g., eczema herpeticum, herpetic
whitlow, herpes gladiatorum), visceral infections, and central nervous system complications (e.g.,
aseptic meningitis, myelitis, encephalitis).
23. What is a Bartholin cyst, and what causes it?
A Bartholin cyst is a noninfectious dilation of the Bartholin gland, which is located at the 4-o’clock and
8-o’clock positions of the labia minora. These glands are mucin secreting and provide vaginal lubrica-
tion through the Bartholin duct, which can become obstructed by infection, inflammation, or physical
blockage (e.g., mucus plug). Obstruction causes the gland to dilate and eventually fill with fluid; this
condition is referred to as a Bartholin cyst, which can be asymptomatic or cause discomfort.
24. Can Bartholin cysts become infected?
Most Bartholin cysts are sterile and contain only the mucinous material produced by the gland.
However, secondary infection can occur. In these cases the cyst becomes filled with purulent material
and is termed a Bartholin abscess. These infections are usually polymicrobial, but N. gonorrhoeae can
sometimes be isolated.
25. How is a Bartholin cyst or abscess treated?
Although treatment is not required for asymptomatic cases, three options are available for symptom-
atic women: incision and drainage, marsupialization, and excision. Most cases respond to incision,
drainage, and placement of a Word catheter. The incision should be approximately 5 mm long and
made on the mucosal surface. The Word catheter keeps the cyst walls from reapproximating and
allows for continued drainage; the goal is for the catheter to stay in place for 4 to 6 weeks to allow for
epithelialization. Wound care generally involves intercourse abstinence, sitz baths, and antibiotics for
surrounding cellulitis or signs of infection.
In the case of recurrence, the cyst wall can be opened and the edges sutured to leave an
open space. This procedure is called marsupialization. Another option is excision of the entire gland
and duct, although this procedure involves significant dissection and requires regional or general
anesthesia.
26. Can Bartholin cysts be malignant?
Most Bartholin cysts are benign and do not need routine biopsy or excision. However, a new cyst in a
woman older than 40 years of age should be examined for possible malignancy.
KEY POINTS: LOWER GENITAL TRACT INFECTIONS
1. Trichomoniasis and candidiasis are diagnosed by visualizing the organisms on microscopy of
vaginal discharge.
2. The presence of bacterial vaginosis is suggested by the “whiff test” and the appearance of “clue
cells.”
3. Syphilis has several stages: primary (vulvar lesion), secondary (systemic rash), latent, and tertiary
(systemic effects).
4. Primary herpes outbreaks are typically more severe and longer in duration than recurrences.
https://t.me/med1917
LOWER GENITAL TRACT INFECTIONS 45
BiBliography
1. Arduino PG, Porter SR. Oral and perioral herpes simplex virus type 1 (HSV-1) infection: review of its management. Oral
Dis. 2006;12:254–270.
2. Baldwin HE. STD update: screening and therapeutic options. Inter J Fertil Womens Med. 2001;46:79–88.
3. Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane
Database Syst Rev. 2013;1. CD000262.
4. Centers for Disease Control and Prevention. Tracking the hidden epidemics 2000: trends in STDs in the United States.
Available at http://www.cdc.gov/std/trends2000/trends2000.pdf. Accessed October 15, 2015.
5. Forna F, Gülmezoglu AM. Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev. 2003;2.
CD000218.
6. Islam A, Safdar A, Malik A. Bacterial vaginosis. J Pak Med Assoc. 2009;59:601–604.
7. Kimberlin DW, Rouse DJ. Clinical practice: genital herpes. N Engl J Med. 2004;350:1970–1977.
8. Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med.
2009;36:388–390.
9. Morris M, Nicoll A, Simms I, et al. Bacterial vaginosis: a public health review. Br J Obstet Gynaecol. 2001;108:
439–450.
10. Ormrod D, Scott LJ, Perry CM. Valaciclovir: a review of its long-term utility in the management of genital herpes
simplex virus and cytomegalovirus infections. Drugs. 2000;59:839–863.
11. U.S. Preventive Services Task Force recommendations for STI screening. Available at
http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-recommendations-for-sti-screening. Accessed
October 15, 2015.
12. Wechter ME, Wu JM, Marzano D, Haefner H. Management of Bartholin duct cysts and abscesses: a systematic review.
Obstet Gynecol Surv. 2009;64:395–404.
13. Workowski KA, Berman S. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment
guidelines, 2010. MMWR Recomm Rep. 2010;59:1–110. x.
https://t.me/med1917
46
1. What is pelvic inflammatory disease (PID)?
PID is a clinical syndrome that comprises a spectrum of inflammatory diseases of the upper female
genital tract: endometritis (infection of endometrium), salpingitis (infection of the fallopian tubes),
tubo-ovarian abscess, and pelvic peritonitis. It is caused by ascending infection from the vagina to the
upper genital organs.
2. What causes PID?
Most cases are polymicrobial. Previously, the most common pathogens were thought to be the sexu-
ally transmitted organisms Neisseria gonorrhoeae and Chlamydia trachomatis. More recent studies
have shown that other organisms in the vaginal flora may also play a crucial role in the development
of PID. These other organisms include enteric gram-negative rods and anaerobes such as Myco-
plasma genitalium, Ureaplasma urealyticum, and Gardnerella vaginalis. Less than half of PID cases
have cervical infection with gonorrhea or Chlamydia, likely from the active screening and treatment of
sexually active women. Cervical or uterine instrumentation may increase the risk of PID.
3. What are the incidence and prevalence of PID?
PID is estimated to occur in more than 750,000 women in the United States every year. These estimates
are limited by the poor sensitivity of clinical diagnostic criteria and the lack of national surveillance.
4. What are risk factors for PID?
• Young age: higher risk of acquiring sexually transmitted infections (STIs)
• History of PID: damaged fallopian tubes are at higher risk for reinfection
• History of gonorrhea or Chlamydia infection
• High-risk sexual behaviors: multiple partners, male partners with gonorrhea or Chlamydia infection
• Bacterial vaginosis
• Socioeconomic status: related to health care access
5. Are intrauterine devices (IUDs) associated with PID?
The risk of developing PID after IUD insertion is highest within the first 3 weeks. Historically, the IUD
would be removed at the time of PID diagnosis. More recent studies, however, do not support this
practice; patients respond just as well to treatment with the IUD in place.
6. What are the clinical symptoms of PID?
Variable. PID may be asymptomatic, or it can manifest with moderate or even severe symptoms (also
known as acute PID). In patients with symptoms, the most common are lower abdominal pain, cramp-
ing, postcoital bleeding, abnormal discharge, fever, nausea, and vomiting. Subclinical PID is more
frequent and leads to misdiagnosis and mistreatment.
7. What are the physical examination findings associated with PID?
During a pelvic examination, the classic sign of PID is cervical motion tenderness or the “chandelier
sign.” This is characterized by severe tenderness or an accompanying reaction to the pain the patient
feels on manipulation of the cervix. Other physical examination findings include adnexal tenderness,
right upper quadrant (RUQ) tenderness (associated with Fitz-Hugh-Curtis syndrome), and mucopu-
rulent discharge on speculum examination.
8. What are the diagnostic criteria for PID?
The Centers for Disease Control and Prevention (CDC) recommend treatment in sexually active
patients if one of the following are met in the absence of any other explanation:
• Uterine tenderness
• Adnexal tenderness (bilateral or unilateral)
CHAPTER 11
PELVIC INFLAMMATORY
DISEASE
Mary Anne M. Baquing, MD
https://t.me/med1917
PELVIC INFLAMMATORY DISEASE 47
• Cervical motion tenderness (“chandelier sign”)
These additional findings support PID diagnosis but are not required:
• Fever higher than 38.3° C
• Abnormal discharge or friable cervix
• White blood cells (WBCs) on saline microscopy (the absence of WBCs makes the diagnosis less likely)
• Cervical infection with gonorrhea or Chlamydia
• Leukocytosis
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Imaging suggestive of a tubo-ovarian abscess or pyosalpinx
• Endometrial biopsy showing endometritis
• Laparoscopic findings consistent with PID
9. What options exist for outpatient treatment of PID?
The following regimens are recommended by the CDC for treatment of PID in the outpatient setting:
• Ceftriaxone 250 mg intramuscularly (IM) in a single dose AND doxycycline 100 mg orally twice a
day for 14 days
• Cefoxitin 2 g IM AND probenecid 1 g orally in a single dose AND doxycycline 100 mg orally twice a
day for 14 days
• Other parenteral third-generation cephalosporin AND doxycycline 100 mg orally twice a day for
14 days
• Consider adding metronidazole to any of the foregoing regimens, especially in patients with bacte-
rial vaginosis.
10. How should patients who receive outpatient treatment be followed?
Patients should be reexamined within 72 hours of treatment. If they do not show significant clinical
improvement, they need to be admitted for parenteral treatment.
11. What are the criteria for inpatient treatment of PID?
• Failed outpatient treatment
• Inability to tolerate or be compliant with an outpatient oral regimen
• Pregnancy
• Presence of tubo-ovarian abscess
• Inability to exclude surgical emergencies such as appendicitis or ectopic pregnancy
• Severe illness (vomiting, high fever)
12. What are the recommended inpatient treatment options for PID?
The CDC recommends the following parenteral regimens:
• Cefotetan 2 g intravenously (IV) every 12 hours OR cefoxitin 2 g IV every 6 hours AND doxycycline
100 mg orally or IV every 12 hours
• Clindamycin 900 mg IV every 8 hours AND gentamicin loading dose of 2 mg/kg
followed by maintenance dose 1.5 mg/kg every 8 hours (A single daily gentamicin dosing of 3 to 5
mg/kg may be considered.)
• Alternative regimen: ampicillin/sulbactam 3 g IV every 6 hours AND doxycycline 100 mg orally or IV
every 12 hours
• If a tubo-ovarian abscess is present, clindamycin or metronidazole should be added to provide
improved anaerobic coverage.
13. What other considerations should be made when treating women for PID?
Women diagnosed with PID should be offered testing for all other STIs. Those who test positive for
gonorrhea or Chlamydia infection during evaluation should be retested 3 to 6 months after treatment
because of high rates of reinfection.
14. How should sexual partners of women diagnosed with PID be managed?
Men who have had sexual contact within 60 days of a women diagnosed with PID should be tested for
STIs and empirically treated for both Chlamydia infection and gonorrhea.
15. What are the potential long-term consequences of PID?
• Infertility
• Tubo-ovarian abscess
• Increased risk of ectopic pregnancy
• Chronic pelvic pain
https://t.me/med1917
48 GENERAL GYNECOLOGY
BiBliography
1. Centers for Disease Control and Prevention. U.S. Selected practice recommendations for contraceptive use, 2013:
Adapted from the World Health Organization Selected Practice Recommendations for Contraceptive Use. 2nd ed. MMWR
Recomm Rep; 2013. 62.
2. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm
Rep. 2015;64:1–137. Available at http://www.cdc.gov/std/tg2015/default.htm. Accessed October 15, 2015.
3. Hoffman B, Schorge J, Schaffer J, et al., eds. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
4. Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol.
2012;120:37–43.
5. Wiesenfeld HC, Hillier SL, Meyn L, et al. Mycoplasma genitalium: is it a pathogen in acute pelvic inflammatory disease
(PID)?. Vienna, Austria: Presented at the STI and AIDS World Congress; 2013 (Joint Meeting of the 20th ISSTDR and 14th
IUSTI Meeting), July 14-27, 2013.
KEY POINTS: PELVIC INFLAMMATORY DISEASE
1. PID is diagnosed by any of the following findings on physical examination: uterine tenderness,
adnexal tenderness, or cervical motion tenderness.
2. The CDC recommends different oral and parenteral regimens for the treatment of PID.
3. Women in whom outpatient therapy fails or who are poor candidates for it should be hospitalized.
4. Long-term sequelae of PID include infertility, tubo-ovarian abscesses, chronic pelvic pain, and
ectopic pregnancy.
https://t.me/med1917
49
1. What is an ectopic pregnancy?
An ectopic pregnancy occurs when an embryo implants itself outside the uterine cavity, usually inside
the fallopian tube.
2. Is ectopic pregnancy a serious condition?
Yes. Although mortality has declined considerably because of early detection, advances in resuscita-
tion, and definitive management, hemorrhagic shock from a ruptured ectopic pregnancy remains the
most common cause of pregnancy-related maternal death in the first trimester. The overall death rate
is approximately 1 death per 2000 ectopic pregnancies.
3. What is the epidemiology of ectopic pregnancy?
The incidence of ectopic pregnancy is estimated to be 1% to 2% of all pregnancies. The incidence
has increased over the past few decades secondary to (1) increased risk factors for salpingitis (e.g.,
Chlamydia trachomatis or Neisseria gonorrhoeae infection), (2) increased detection of unruptured ectopic
pregnancies by using more advanced diagnostic strategies, and (3) assisted reproductive technology
(ART). Patients in the first trimester of pregnancy who present to an emergency department with vaginal
bleeding, abdominal pain, or both have approximately a 10% chance of having an ectopic pregnancy.
4. What are the risk factors for ectopic pregnancy?
Anything that may impede embryo movement from the fallopian tube to the uterus confers an
increased risk. Keep in mind that because ectopic pregnancy is so common, half of all women who
are diagnosed have no risk factors.
• Salpingitis from sexually-transmitted infections is the major contributing factor, with an odds ratio
(OR) of 3.5. The increased incidence of ectopic pregnancy in patients with a history of salpingitis
results from inflammation and morphologic changes that occur in the fallopian tube after infection.
• A history of tubal surgical intervention also increases risk (OR, 3.5), but this is mainly attributable to
the underlying cause of the surgical procedure (e.g., salpingitis with a tubo-ovarian abscess, previ-
ous ectopic pregnancy).
• Smoking causes ciliary dysmotility in the fallopian tubes and predisposes to ectopic pregnancy in a
direct dose-response relationship (OR, 2, which rises to 4 if a patient smokes more than one pack/
day).
• A history of an earlier ectopic pregnancy carries a very large risk; approximately 25% of subse-
quent pregnancies will also be ectopic.
• Women who have been exposed to diethylstilbestrol (DES) in utero have a 5% risk of ectopic
pregnancy; this risk rises to 13% if abnormalities are seen on a hysterosalpingogram.
• Although it is very rare for a patient with an intrauterine device (IUD) to become pregnant, the risk
of an ectopic pregnancy is high if it happens.
5. Where do ectopic pregnancies implant, if not inside the uterus?
Almost all ectopic pregnancies implant in the fallopian tube (97.7%) (Fig. 12-1). Most tubal pregnan-
cies implant in the ampullary portion of the tube (>80%), but they can also implant in the isthmus
(12%) and fimbrial region (5%). Ectopic pregnancies that do not occur in the fallopian tube are rare
(2.3%), and they are interstitial (also referred to as “cornual”), cervical, or abdominal pregnancies. The
risk of hemorrhagic shock and death from an interstitial or abdominal pregnancy is five times greater
compared with a tubal pregnancy.
6. What is a heterotopic pregnancy, and what is the incidence?
A heterotopic pregnancy is defined as the coexistence of an intrauterine pregnancy (IUP) and an ecto-
pic pregnancy. Previous estimates for heterotopic pregnancy were 1 in 30,000, but it is likely as com-
mon as 1 in 4000 (albeit still very rare). Heterotopic pregnancy should always be seriously considered
in women undergoing ART; depending on the technique used, the risk of an associated heterotopic
pregnancy can be as high as 1 in 100.
CHAPTER 12
ECTOPIC PREGNANCY
Ryan Pedigo, MD
https://t.me/med1917
50 GENERAL GYNECOLOGY
7. What are the most common symptoms of an ectopic pregnancy?
An ectopic pregnancy should be considered in any pregnant patient who has abdominal pain or
vaginal bleeding. All women of reproductive age who present with these complaints should receive a
pregnancy test. Because a standard urine pregnancy test can detect human chorionic gonadotropin
(hCG) levels as low as 20 mIU/mL, a negative result almost always rules out the diagnosis. In a patient
with a positive pregnancy test result, additional evaluation is necessary.
8. How is an ectopic pregnancy diagnosed?
Evaluation begins with a urine pregnancy test; if the result is negative, an ectopic pregnancy is
excluded. If the urine pregnancy test result is positive and the patient stable, serologic testing and
ultrasonography should be performed.
The following tests should always be ordered:
1. Serum quantitative hCG (discussed later in question 9).
2. Blood type and antibody screen; women with vaginal bleeding who are Rh negative require anti-D
immunoglobulin (RhoGAM) to prevent isoimmunization and hemolytic disease of the newborn in
subsequent pregnancies.
3. Hemoglobin level; keep in mind that this can be normal in the early stages of acute blood loss.
Significant anemia is cause for concern.
A transvaginal ultrasound (TVUS) scan should be performed to attempt to locate the pregnancy. Four
general categories of results are seen:
1. Nondiagnostic: Normal anatomy is present, but no IUP is identified.
2. Suggestive of ectopic pregnancy: An adnexal mass is present, and no IUP is seen.
3. Diagnostic of an ectopic pregnancy: A gestational sac with a yolk sac or embryo is seen outside the
uterine cavity.
4. Diagnostic of an IUP: A gestational sac with a yolk sac or embryo is seen inside the uterine cavity.
If a pregnant patient has not undergone ART, the diagnosis of ectopic pregnancy is essentially
excluded in the presence of an IUP.
9. In patients without an IUP on TVUS, how does the quantitative hCG determination
help?
If no IUP is visualized on TVUS, a quantitative hCG determination can guide management. A single
level guides interpretation of ultrasound results on that day, and serial levels can be used to guide
prognosis and management in the outpatient setting. Evidence of an IUP (i.e., a gestational sac) should
Cornual
(4 patients)
Cervical
(1 patient)
Abdominal
(9 patients)
Proximal third
(79 patients)
Middle third
(245 patients)
Distal third
(265 patients)
Fimbrial
(30 patients)
Fimbrial ovarian
(10 patients)
Ovarian
(1 patient)
Interstitial
(8 patients)
Tubal
Abdominal
Uterine
Ovarian
Total
97.72%
1.37%
0.76%
0.15%
100.00%
639 patients
9 patients
5 patients
1 patient
654 patients
Figure 12-1. Locations of implantation in ectopic pregnancy. (From Lentz GM, Lobo RA, Gershenson DM, et al, eds.
Comprehensive Gynecology. 6th ed. Philadelphia: Mosby; 2012.)
https://t.me/med1917
ECTOPIC PREGNANCY 51
be seen with TVUS when the hCG level reaches approximately 1500 mIU/mL, and an IUP is virtually
always seen when hCG exceeds 2500 mIU/mL. Traditionally, a quantitative hCG level of 1500 mIU/mL
has been called the discriminatory zone because this is the level at which one expects to visualize
an IUP if the pregnancy is normal. However, more recent data support a higher threshold, with 99% of
gestational sacs visible with TVUS when the hCG level reaches 3500 mIU/mL. Absence of an IUP on
TVUS with an hCG greater than the discriminatory zone is highly suggestive of an abnormal pregnancy
(either an ectopic pregnancy or a nonviable intrauterine gestation). If a patient without an IUP on ultra-
sound has an hCG level lower than the discriminatory zone and is stable, she can be followed with a
repeat hCG level in 48 hours. These patients should be instructed to seek emergency medical care if
they have worsening abdominal pain, lightheadedness or syncope (concerning for blood loss), or other
concerns.
The discriminatory zone for transabdominal ultrasound is much higher (6000 mIU/mL) because
it is much more difficult to visualize an early IUP with this method. However, some providers prefer to
perform a transabdominal ultrasound scan first because visualization of an IUP eliminates the need for
a subsequent TVUS (Tables 12-1 and 12-2).
10. How are serial quantitative hCG measurements useful?
In patients who have an hCG lower than the discriminatory zone and who are stable for discharge,
serial hCG levels can guide outpatient management (Fig. 12-2). In early pregnancy (before 6 to
7 weeks of gestation), hCG normally doubles every 48 hours and should increase by at least 66%. If
the level does not rise significantly or declines, a nonviable pregnancy (either ectopic or spontaneous
abortion) is highly likely. If the level rises to greater than the discriminatory zone and no IUP is identi-
fied, suspicion of an ectopic pregnancy should increase.
11. Can other blood tests predict the viability of a pregnancy?
Progesterone levels can potentially be used to predict pregnancy viability, although most hospitals
cannot readily perform this test and produce a result within the same patient visit. In one large series,
all women in the first trimester of pregnancy who had a serum progesterone level lower than 5 ng/mL
had an abnormal pregnancy (ectopic or nonviable IUP), and almost all women (97%) with a proges-
terone level higher than 25 ng/mL were eventually diagnosed with a viable IUP. This is test is not
currently considered part of the standard workup for ectopic pregnancy.
Table 12-1. Normal Intrauterine Pregnancy
GESTATIONAL AGE STRUCTURES
4-5 weeks from LMP Eccentrically placed small gestational sac
5 weeks from LMP Double decidua sign (two echogenic rings surrounded by intrauter-
ine fluid collection); can be mistaken for pseudo-sac
5.5 weeks from LMP Diagnostic findings start here:
Yolk sac visualized within gestational sac
6 weeks from LMP Embryonic pole
6.5 weeks from LMP Fetal cardiac activity present
LMP, Last menstrual period.
Table 12-2. Ectopic Pregnancy
Extrauterine pregnancy
Yolk sac or fetal pole (100% positive predictive value for
ectopic pregnancy) is diagnostic
Ring sign Adnexal mass with hyperechoic ring surrounding gestational
sac
Nonhomogenous mass (not ovarian) Positive predictive value for ectopic pregnancy is 80% to 90%
https://t.me/med1917
52 GENERAL GYNECOLOGY
12. What is the role of dilation and curettage (D&C) in the diagnosis of an ectopic
pregnancy?
When a patient has a nondiagnostic TVUS and the hCG level is greater than the discriminatory zone,
D&C can be considered for both diagnostic and therapeutic purposes. However, this option is reserved
for undesired pregnancies. If chorionic villi are identified by histologic examination of the tissue
obtained during the procedure, a nonviable IUP was present, and the patient is considered to have
received definitive treatment (i.e., therapeutic abortion). If chorionic villi are not identified, the diagno-
sis of an ectopic pregnancy is presumed. A D&C can also be considered in patients with an abnormally
low rate of rise in hCG because this indicates an abnormal pregnancy.
13. How is an ectopic pregnancy managed medically, and who is eligible?
Medical management of an ectopic pregnancy is achieved with methotrexate (MTX), a folic acid
antagonist. In properly selected patients, outcomes are comparable to those of surgical intervention.
Before the patient receives MTX, the following laboratory tests should be ordered: complete blood
count (CBC), chemistry panel, liver function tests (LFTs), quantitative hCG, blood type, and antibody
screen. Absolute contraindications to MTX are breastfeeding, immunodeficiency, blood dyscrasias,
active pulmonary disease, any renal or hepatic dysfunction, alcoholism, or active peptic ulcer disease.
The ideal patient for MTX therapy (1) is asymptomatic or minimally symptomatic with an
unruptured tubal ectopic pregnancy, (2) is reliable for follow-up, and (3) has an hCG level higher than
100
75
50
25
0
–25
–50
–75
Patients with intrauterine pregnancies
Patients with ectopic pregnancies
Patients with spontaneous abortions
–100
02
Change in hCG level (%)
Days
Spontaneous abortions
Intrauterine pregnancies
99% of
patients
21% of patients
1% of patients
71% of
patients
10% of patients
8% of patients
90% of
patients
Ectopic pregnancies
Figure 12-2. Change in human chorionic gonadotropin (hCG) level over 48 hours (2 days) in intrauterine pregnan-
cies, ectopic pregnancies, and spontaneous abortions. (From Lentz GM, Lobo RA, Gershenson DM, et al, eds. Compre-
hensive Gynecology. 6th ed. Philadelphia: Mosby; 2012.)
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана