Thread by @OBGynChallenge

1/ OK, so today #OBGynInternChallenge diagnosed an ectopic! What do you do once that's accomplished? Let's talk about treatment with a #tweetorial! We'll do these occasionally to cover content we couldn't get to in our @learnarist course. Bonus knowledge! #MedEd #FOAMed #FOAMob

2/ When you think about #treatment for any medical condition, it can be helpful to organize your thoughts into three broad categories: #medical, #surgical, and #expectant. We often forget about that last one! #MedTwitter #OBGynTwitter

3/ With #ectopic #pregnancy, #surgery is what you probably think of first. It's appropriate in three cases: 1) hemodynamically unstable patient; 2) a patient who desires surgery instead of medical therapy; 3) a patient has a contraindication to medical therapy.

4/ #Surgery can generally be laparoscopic. Techniques are 1) salpingostomy - opening the tube to extract the ectopic; or 2) salpingectomy, removing the entire tube. The latter is easier to accomplish, and doesn't seem to result in #fertility loss (unless both tubes are gone!)

5/ #Medical therapy is with the anti-folate drug #methotrexate. There are absolute and relative contraindications to MTX therapy - from @acog - learn these! Note the relative contraindications - "high hCG" generally means over 5,000 mIU/mL, where failure may be as high as 15%.

6/ Dosing regimens with MTX are also variable and could be their own #MedTweetorial, so review @acog PB 193 for info on those! Pts should also be made aware of MTX side effects: bc it affects rapid-dividing tissues, GI upset, nausea/vomiting, and stomatitis are common.

7/ After MTX treatment, pt needs close monitoring to ensure the hCG level continues to fall. If it doesn't fall >15% between day 4 and 7 after administration, repeat doses are often required! Monitoring is often complete within a month, but may take as long as 8 weeks!

8/ What about expectant management? We'll pick on @DrOlgaTheOBGYN since she posted on this just a few days ago - there's likely a role for it! Pt should be asymptomatic, objective evidence of resolution, and well-counseled on the risks.

9/ Check out her thread to see some thoughts in #OBGynTwitter land! The PB 193 makes reference to a single trial comparing single dose MTX to expectant mgmt in its with bHCG < 2000, with success rates not statistically different (76% vs 59% respectively).

https://twitter.com/DrOlgaTheOBGYN/status/1389793726793273348

10/10 🔑points:
🔑 #Ectopic treatments: #medical, #surgical, and #expectant.
🔑 #Surgery is done by salpingectomy or salpingostomy.
🔑 #MTX is the medical therapy of choice - know those indications and contraindications!
🔑 @acog PB 193 is an excellent resource for more info!