Gravidez ectópica não rota: diagnóstico e tratamento. Situação atual

Abstract

It is advisable to do the non-invasive diagnosis of ectopic pregnancy precociously, before there is the tube rupture, combining for that the transvaginal ultrasonography with the dosage of the b-fraction of the chorionic gonadotrophin. A range of treatment options may be used. Either a surgical intervention or a clinical treatment may be taken into consideration. Laparotomy is indicated in cases of hemodynamic instability. Laparoscopy is the preferential route for the treatment of tube pregnancy. Salpingectomy should be performed in patients having the desired number of children, while salpingostomy should be indicated in patients willing to have more children, when the b-hCG titers are under 5,000 mUI/mL and the surgical conditions are favorable. The use of methotrexate (MTX) is a consecrated clinical procedure and should be indicated as the first option of treatment. The main criteria for MTX indication are hemodynamic stability, b-hCG <5,000 mUI/mL, anexial mass <3,5 cm, and no alive embryo. It is preferable a single intramuscular dose of 50 mg/m(2), because it is easier, more practical and with less side effects. Protocol with multiple doses should be restricted for the cases with atypical localization (interstitial, cervical, caesarean section scar and ovarian) with values of b-hCG >5,000 mUI/mL and no alive embryo. Indication for local treatment with an injection of MTX (1 mg/kg) guided by transvaginal ultrasonography should occur in cases of alive embryos, but with an atypical localization. An expectant conduct should be indicated in cases of decrease in the b-hCG titers within 48 hours before the treatment, and when the initial titers are under 1,500 mUI/mL. There are controversies between salpingectomy and salpingostomy, concerning the reproductive future. Till we reach an agreement in the literature, the advice to patients who are looking forward to a future gestation, is to choose either surgical or clinical conservative conducts.

Diagnosis of Heterotopic Pregnancy Using Ultrasound and Magnetic Resonance Imaging in the First Trimester of Pregnancy: A Case Report

“…The most commonly present extrauterine images in transvaginal 2DUS in heterotopic pregnancies consist of complex cysts or adnexal masses, which may comprise hematosalpinx, tubal ring, or even a live embryo, with or without accompanying free fluid in the peritoneal cavity [6]. However, 2DUS may often be indeterminate, and in such cases, MRI of the pelvis may be used to assist in the diagnosis [7], as shown in the present paper.…”

The Value of Hysterosalpingography following Medical Treatment with Methotrexate for Ectopic Pregnancy

“…Indications for conservative treatment with methotrexate (MTX) were [14] hemodynamic stability without evidence of active bleeding or hemoperitoneum, willingness of having future progeny, possibility of followup, absence of contraindications for MTX, gestational sac with maximum diameter of 4 cm, and no embryonic cardiac motion.…”

Surgical treatment of tubal ectopic pregnancy through posterior colpotomy: experience from a Brazilian university hospital

“…Values given are the mean±standard deviation or number (%).hCG, human chorionic gonadotropin. a) Risk factors for a poor prognosis in response to treatment with methotrexate [2]. …”

“…The advent of transvaginal ultrasound along with the possibility of dosing serum β-human chorionic gonadotropin (hCG) have made it possible to diagnose early ectopic pregnancies, some of which can be managed with non-surgical approaches, such as expectant management and pharmacological treatment with methotrexate [2]. However, surgery continues to be the most important intervention for the prevention of tubal rupture and severe hemorrhage.…”