Re: Tubal Pregnancy--management
From: Terrence.Jones@kp.org
Tue Jan 22 13:50:56 2008
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Sorry for the late entry, just catching up. Was the situation You have
recently seen (multiple with titres above singleton discriminatory zone)
associated with a 48 hour f/u titre of < 50% rise, and another 72 hour f/u
titre also of < 50% rise? /tj
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evsono@pipeline.com (art fougner, md)
Sent by: ob-gyn-l@obgyn.net
01/19/2008 10:22
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Re: Tubal Pregnancy--management
A word of caution for those who would give MTX in a stable patient
simply because their HCG comfort zone has been exceeded - Multiple
Pregnancy. Levels of HCG may be significantly elevated prior to first
visualization on sonar. Having recently seen this situation, I urge all
to keep this in mind, prior to interrupting an early twin intrauterine
pregnancy.
Of course, that's just my opinion. I could be wrong.
Art
At Sat, 19 Jan 2008, Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C.
wrote:
>
>At Sat, 19 Jan 2008, Garry E. Siegel, M.D. wrote:
>>
>>20 YO P0, seen in ER and office as follows:
>>
>>1/13--acute abdominal pain requiring narcotics, got better. Exam per ER
>>MD negative, HCG 1300, Hemoglobin 15, ultrasound empty uterus and 3 cm.
>>cyst left side.
>>
>>1/15--asymptomatic except spotting, HCG 1900, Hemoglobin 15, negative
>>exam by me. Ultrasound no change.
>>
>>1/18--HCG now 2800 from 1/17, progesterone 5.4 from 1/17, exam and
>>ultrasound unchanged.
>>
>>Would you have made a dispostion on 1//15?
>>
>>If so, what?
>>
>>If not, now it is 1/18 and I made a dispostion.
>>
>>Would you:
>>
>>1. D and C, frozen section, and scope if negative?
>>2. D and C, await pathology, give methotrexate?
>>3. Give methotrexate primarily?
>>
>>More to discuss once replies come in. . .
>>
>>Garry
>
>First I get the feeling this is a very wanted pregnancy, in which case I
>would also have done nothing on the 15th.; 1300 -1900 is not good but I
>have seen normal pregnancies with similar changes.
>
>I would have gone with D&C and scope, I don't find frozen section very
>helpfull. Having had to take care of about half a dozen MTX disasters
>in the the last decade, I don't feel comfortable using it in my practise
>setting.
>
>I recently had a similar case, BHCG 1000-1500 -1700, Q 2daily then 1700
>again, told patient not looking good. brought in for D&C and scope; D&C
>looked like mostly deciduia so scoped and saw normal tubes but had a
>small fibroid 3cm fibroid on back wall of uterus, I thought it was a
>septum on D&C, in view of normal tubes repeated D&C concentrating
>suction behind the fiboid and got more tissue. Yes the pregnancy was
>stuck behind and to the side of the fibroid.
>
>--
> Take care, John
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
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<br><font size=2 face="sans-serif">Sorry for the late entry, just catching
up. Was the situation You have recently seen (multiple with titres above
singleton discriminatory zone) associated with a 48 hour f/u titre of <
50% rise, and another 72 hour f/u titre also of < 50% rise? /tj<br>
<br>
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<td width@%><font size=1 face="sans-serif"><b>evsono@pipeline.com (art
fougner, md)</b> </font>
<br><font size=1 face="sans-serif">Sent by: ob-gyn-l@obgyn.net</font>
<p><font size=1 face="sans-serif">01/19/2008 10:22</font>
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<div alignÎnter><font size=1 face="sans-serif">Please respond to<br>
ob-gyn-l@obgyn.net</font></div></table>
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<td>
<div align=right><font size=1 face="sans-serif">To</font></div>
<td valign=top><font size=1 face="sans-serif">Multiple recipients of list
OB-GYN-L <ob-gyn-l@mail.obgyn.net></font>
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<div align=right><font size=1 face="sans-serif">Subject</font></div>
<td valign=top><font size=1 face="sans-serif">Re: Tubal Pregnancy--management</font></table>
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<table>
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<td></table>
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<br>
<br><font size=2><tt>A word of caution for those who would give MTX in
a stable patient<br>
simply because their HCG comfort zone has been exceeded - Multiple<br>
Pregnancy. Levels of HCG may be significantly elevated prior to first<br>
visualization on sonar. Having recently seen this situation, I urge
all<br>
to keep this in mind, prior to interrupting an early twin intrauterine<br>
pregnancy.<br>
<br>
Of course, that's just my opinion. I could be wrong.<br>
<br>
Art<br>
<br>
At Sat, 19 Jan 2008, Dr. John Provatopoulos B.Sc. M.D.C.M.
F.R.S.C.<br>
wrote:<br>
><br>
>At Sat, 19 Jan 2008, Garry E. Siegel, M.D. wrote:<br>
>><br>
>>20 YO P0, seen in ER and office as follows:<br>
>><br>
>>1/13--acute abdominal pain requiring narcotics, got better. Exam
per ER<br>
>>MD negative, HCG 1300, Hemoglobin 15, ultrasound empty uterus and
3 cm.<br>
>>cyst left side.<br>
>><br>
>>1/15--asymptomatic except spotting, HCG 1900, Hemoglobin 15, negative<br>
>>exam by me. Ultrasound no change.<br>
>><br>
>>1/18--HCG now 2800 from 1/17, progesterone 5.4 from 1/17, exam
and<br>
>>ultrasound unchanged.<br>
>><br>
>>Would you have made a dispostion on 1//15?<br>
>><br>
>>If so, what?<br>
>><br>
>>If not, now it is 1/18 and I made a dispostion.<br>
>><br>
>>Would you:<br>
>><br>
>>1. D and C, frozen section, and scope if negative?<br>
>>2. D and C, await pathology, give methotrexate?<br>
>>3. Give methotrexate primarily?<br>
>><br>
>>More to discuss once replies come in. . .<br>
>><br>
>>Garry<br>
><br>
>First I get the feeling this is a very wanted pregnancy, in which case
I<br>
>would also have done nothing on the 15th.; 1300 -1900 is not good but
I<br>
>have seen normal pregnancies with similar changes.<br>
><br>
>I would have gone with D&C and scope, I don't find frozen section
very<br>
>helpfull. Having had to take care of about half a dozen MTX disasters<br>
>in the the last decade, I don't feel comfortable using it in my practise<br>
>setting.<br>
><br>
>I recently had a similar case, BHCG 1000-1500 -1700, Q 2daily then
1700<br>
>again, told patient not looking good. brought in for D&C
and scope; D&C<br>
>looked like mostly deciduia so scoped and saw normal tubes but had
a<br>
>small fibroid 3cm fibroid on back wall of uterus, I thought it was
a<br>
>septum on D&C, in view of normal tubes repeated D&C concentrating<br>
>suction behind the fiboid and got more tissue. Yes the pregnancy
was<br>
>stuck behind and to the side of the fibroid.<br>
><br>
>--<br>
>
Take care, John<br>
><br>
<br>
--<br>
art fougner, md<br>
"May The Wings of Liberty Never Lose a Feather." - Jack Burton<br>
</tt></font>
<br>
