Management of Ectopic Pregnancy:

Three different options for managing an ectopic pregnancy:

• Surgery (salpingostomy= incision into the tube/salpingectomy= actually removing the tube)
• Medical (methotrexate)
• Expectant management

Patients who are diagnosed early are typically treated with medical management (MTX) and the remaining patients will need surgery (reasons for surgery= if you suspect a ruptured tube, large ectopic pregnancy). Only a limited number of patients with be considered eligible for expectant management.

ALGORITHM: MTX is the preferred treatment option when a patient has all of the following: hemodynamically stable, beta-HCG level is <5000, no fetal cardiac activity detected on transvaginal ultrasound, and the patient is willing to comply with post-treatment follow up & has access to emergency medical services in case fallopian tube ruptures.

Methotrexate contraindications: if there is a co-existing viable intrauterine pregnancy, breastfeeding, hypersensitivity to methotrexate, abnormal baseline lab values (hematologic, renal, hepatic), immunodeficiency, active pulmonary disease, or peptic ulcer disease [if any of those are present= need to do surgical route instead]

 

Placental Abruption:

Placental abruption (also known as abruptio placentae)= defined as premature partial or complete separation of the placenta before delivery of fetus. Typically you’ll see this in pregnancies over 20 weeks of gestation. Risk factors include a previous history of abruption, HTN, previous premature rupture of membrane, cigarette smoking, cocaine use. Signs and symptoms include painFUL vaginal bleeding, abdominal or back pain, uterus can be rigid or tender. About 10-20% of patients will present with preterm labor but without the bleeding because the blood can be trapped and concealed within the uterine cavity.

Most of the time it’s a clinical diagnosis. But a transabdominal ultrasound can be used to diagnose- see a retroplacental hematoma/clot finding. Positive predictive value is about 88% when the ultrasound suggests placental abruption so its not 100% reliable but it can be helpful to differentiate between previa and abruptio. In terms of management it would depend on how the mother is doing whether she is unstable or stable and if the fetus is viable or not. The initial approach for all patients is similar though to what we did with our patient- having continuous fetal heart rate monitoring, secure IV access and start large bore IV, and closely monitor the mother’s hemodynamic status by keeping an eye on her vitals.

Regarding whether or not you should do a pelvic exam- the general rule of thumb is NOT to do it on a pregnant patient with vaginal bleeding because you haven’t determined the exact location of the placenta. You would accomplish this by using the ultrasound to rule out placenta previa, because a pelvic exam would initiate profuse bleeding in that case.

 

Pap Smear Screening:

NORMAL: For a patient who is 21-29 years old  pap every 3 years; If patient is over 30 and HPV negative they have the option to do a “combo” which is HPV & Pap together every 5 years, or you can still do the pap every 3 years like under 30. If patient is over 30 and HPV positive though that would require either co-testing every year or HPV genotype testing

 

ASCUS [atypical squamous cells of undetermined significance]: For a patient 21-24 years old preferred to do a pap every year or reflex HPV test; Patient 25-29 years old preferred to do reflex HPV testing or pap testing in 1 year is also acceptable. For patients over 30 and HPV negative they would repeat co-testing every 3 years, and if they’re over 30 but HPV positive you would perform a colposcopy.

 

LSIL [low grade squamous intraepithelial lesion]: 21-24 year old= repeat pap in 1 year, 25-29= colposcopy, over 30 and HPV negative= repeat pap in 1 year or colposcopy; over 30 and HPV positive= colposcopy

 

ASC-H [atypical cells that can’t exclude high grade squamous]: all four categories= colposcopy

 

HSIL [high grade squamous cell intraepithelial lesion]: 21-24 is colposcopy and the other 3 categories are either excisional treatment of colposcopy

*Colposcopy: examining the cervix using a scope and performing a biopsy

*Excisional treatment options include: loop electrosurgical excision procedure (LEEP), cold-knife conization, laser conization

*LEEP= uses a thin wire loop and an electrical current to remove the abnormal tissue

*Cold knife= scalpel used to remove the abnormal tissue

*Laser conization= laser beam used to destroy the abnormal tissue

 

Journal Article & Summary:

OBGYNArticle

This systematic review and meta-analysis published in the American Journal of Obstetrics and Gynecology in April 2017 determined the effectiveness of long-acting reversible contraception (LARC). Highly effective contraception can help reduce the incidence of unintended pregnancies among adolescent patients, thereby warranting this study.

Data was collected using specific key terms, and featured both intrauterine devices as well as etonogestrel implant (Nexplanon) as examples of LARC. Ultimately out of the 1677 articles, only 12 were included in the final analysis (6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial). These studies featured 4886 women that were under the age of 25, 4131 IUDs and 755 implants. The 12 month continuation of both these LARCs were analyzed and it was estimated to be 84%, with IUD specifically at 74% and implant at 84%.

Overall this study demonstrated that adolescent continuation of LARC methods is high at 12 months, including patients who had devices placed post partum in addition to nulliparous patients as well. Strengths of this review include the large sample size as well as the accuracy of continuation of LARCs. A weakness of this review is that there was signifiant heterogeneity among the individuals in addition to only including women up to 25 years old. This review yielded helpful information for clinical practice, as it indicates that adolescents can be offered LARC as a first line contraceptive option to help decrease the rates of unintended pregnancy.