0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57
Pregnancy Complications for the Internist 1203➣If pregnancy not desired or progesterone below threshold for via-
bility or beta-HCG >2000 mIU/mL or beta-HCG increases >66%
in 48 h, D&C indicated
➣No chorionic villi in D&C: treat for presumed ectopic pregnancy
➣Serum progesterone above threshold of viability and beta-HCG
increases >66% in 48 h: repeat beta-HCG q 48 h until it reaches
2000 mIU/mL; no intrauterine gestational sac seen on US, treat
for ectopic pregnancy
■Specific Treatment
➣Threatened abortion: reassurance and bed rest, but 50% abort
➣Missed abortion: D&C vs expectant management (may sponta-
neously abort)
➣Inevitable abortion: D&C if incomplete; otherwise, expectant
management
➣Septic abortion: broad-spectrum antibiotics, D&
➣GTN: D&C followed by weekly beta-HC
When beta-HCG (–) for 2 consecutive wks, monitor beta-HCG
monthly for 1 y
Treat with contraception for 1 y
80% cured with D&C
➣Ectopic pregnancy: Surgical vs. medical management
Surgical management by laparoscopy or laparotomy, salp-
ingectomy or linear salpingostomy
Medical management appropriate if ALL the following present:
Beta-HCG <5–10,000 mIU/mL, hemodynamically stable, no
significant pain, adnexal mass <3.5 cm, no cardiac activity in
the adnexal mass, no significant fluid in pelvis per US and AST,
creatinine and BUN normal
Treat with IM methotrexate
Check beta-HCG days 4 and 7; if <15% beta-HCG decline,
repeat dose if patient stable
■Side Effects
➣Methotrexate: nausea, vomiting, rash, pruritus, dizziness,
fatigue, headache, neurotoxicity, leukoencephalopathy, renal
failure, photosensitivity, seizure, thrombocytopenia, hepatoxi-
city
■Contraindications
➣Methotrexate: lactation, alcohol abuse, liver dysfunction, infec-
tion, renal impairment
■Special Situations