A 34-year-old woman comes to the office due to a positive home pregnancy test, which she took after developing daily nausea and vomiting. The patient has had no vaginal bleeding or cramping. She has no chronic medical conditions and has had 2 cesarean deliveries. The patient's last delivery was 8 months ago, and she is still breastfeeding her infant. Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 76/min. Cardiopulmonary examination is normal. The abdomen is soft, nontender, and nondistended. Pelvic examination reveals a small, mobile uterus. Serum β-hCG level is 6,134 mIU/mL. A transvaginal ultrasound shows a uterus with a thin endometrial stripe and a 5-cm complex mass with fetal cardiac activity. The mass appears within the interstitial segment of the proximal fallopian tube and embedded in the myometrium. Bilateral adnexa appear normal. There is no free fluid in the pelvis. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman comes to the office due to a positive home pregnancy test, which she took after developing daily nausea and vomiting.  The patient has had no vaginal bleeding or cramping.  She has no chronic medical conditions and has had 2 cesarean deliveries.  The patient's last delivery was 8 months ago, and she is still breastfeeding her infant.  Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 76/min.  Cardiopulmonary examination is normal.  The abdomen is soft, nontender, and nondistended.  Pelvic examination reveals a small, mobile uterus.  Serum β-hCG level is 6,134 mIU/mL.  A transvaginal ultrasound shows a uterus with a thin endometrial stripe and a 5-cm complex mass with fetal cardiac activity.  The mass appears within the interstitial segment of the proximal fallopian tube and embedded in the myometrium.  Bilateral adnexa appear normal.  There is no free fluid in the pelvis.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da2a_889b_bc81_df7738eca565_MD0003_00 This patient has a complex mass with fetal cardiac activity located within the interstitial segment of the proximal fallopian tube. This finding is consistent with a cornual ectopic pregnancy, a potentially life-threatening condition due the high risk of fallopian tube rupture and hemorrhage. Patients may be asymptomatic or have normal symptoms of pregnancy (eg, nausea/vomiting, breast tenderness). The ectopic pregnancy is usually diagnosed on pelvic ultrasound, which typically reveals a thin endometrium and a pregnancy outside the uterine cavity. proximal fallopian tube Management of ectopic pregnancy is either medical (ie, methotrexate) or surgical, depending on maternal hemodynamic status and ability to tolerate methotrexate therapy (Choice D). Methotrexate is a folate antagonist that inhibits DNA synthesis, particularly in rapidly proliferating cells (eg, cytotrophoblasts). However, the large dose required for treatment can affect other cell types, especially in patients with certain underlying conditions. Therefore, absolute contraindications to methotrexate include the following: Hematologic abnormalities (eg, anemia, thrombocytopenia) and immunosuppression (eg, HIV) due to the increased risk for bone marrow suppression and pancytopenia Active pulmonary disease due to the risk for pulmonary toxicity Hepatic or renal disease due to decreased drug metabolism and clearance, which increases the risk for methotrexate toxicity (eg, acute respiratory distress syndrome, bowel ischemia) Breastfeeding due to the transfer to breast milk, which can cause toxic levels in the infant (Choice A) In addition to having an absolute contraindication to methotrexate therapy, this patient also has several relative contraindications, including an adnexal mass ≥3.5 cm, the presence of fetal cardiac activity, and a β-hCG level ≥5,000 IU/L (all of which are associated with an increased risk of methotrexate treatment failure). In patients with these findings, the best next step in management is surgical removal of the ectopic pregnancy. (Choice B) Mifepristone and misoprostol cause uterine contractions and are used for the medical management of spontaneous abortions; they are not used to treat ectopic pregnancy. (Choice C) Stable patients with a pregnancy of unknown location (ie, positive pregnancy test, no intrauterine or extrauterine pregnancy on ultrasound) usually require a repeat β-hCG level and transvaginal ultrasound in 48 hours. However, once an ectopic pregnancy is identified, prompt medical or surgical treatment is indicated because treatment delay increases the risk for fallopian tube rupture. Educational objective: Patients with an ectopic pregnancy require surgical management when they have medical contraindications to methotrexate (eg, breastfeeding) or are hemodynamically unstable. References: Medical management of ectopic pregnancy: a comparison of regimens. (http://www.ncbi.nlm.nih.gov/pubmed/22510626) The non-surgical management of ectopic pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/16374758)

A 34-Year-Old Woman Comes to the Office Due to a Positive