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Re: Tubal Pregnancy--managementFrom: Glen Elrod (dr99645@yahoo.com)Mon Jan 21 15:21:17 2008
Garry, Did you see the ectopic before going to the OR? I remember you saw the cyst, but that seemed to be the tubal cyst not an ectopic. I would lean toward salpingectomy, given the increased risk of recurrent ectopic on that side with a damaged tube and prior PID. But, you have to be there as you said. Glen
>----- Original Message ---- Fun discussion on a snowy day in Georgia. My $0.02: 1. I don't think that expectant management is appropriate here. I gave her the benefit of the doubt on 1/15 when the uterus was empty and the HCG was 1900. The 2800 HCG AND a poor progesterone of 5.4 to me meant that there was no chance of this being a viable single or twin intrauterine pregnancy. 2. I have heard a figure (I think that it was from an ACOG update CD on medical management of ectopics) that up to 40% of cases where there is no sac and the HCG exceeds the discriminatory zone have abnormal intrauterine pregnancies. Thus, I am very reluctant to give methotrexate without emptying the uterus. Furthermore, FWIW, I have been less than impressed with methotrexate, and it takes an educated and motivated patient to accept it. In this case, this young woman (20) was nice but really didn't "get" her situation despite lots of talking, diagrams, etc. So, that said, I can't remember the last time that I went to the OR in a case like this and found POC in the uterus. AND. . .I really can't see going to the OR for a D and C, and then giving methotrexate a day or two later after the pathology is back. If she's asleep, and she doesn't have an IUP, why not scope her? So. . . D and C this AM--very little tissue, frozen negative for villi. At laparoscopy, had old PID and the left tube had a mid-ampullary 3 cm ectopic, with a huge reactive tubal cyst or hydatid (around 3 to 4 cm.) on the tube. The right side had filmy adhesions binding the adnexa down to the sidewall but the tube and fibriae looked OK. Salpingostomy or salpingectomy? (hard to say without being there, I know). Garry
-- Garry E. Siegel, M.D. Private Practice Roswell, GA
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