VI.

MEDICAL MANAGEMENT

A. Ideal Management
Determining if a patient is a candidate for methotrexate therapy 1. Methotrexate y Single-dose regimen protocol y Two-dose regimen protocol y Fixed multidose regimen protocol 2. Surveillance after methotrexate therapy y Serial hCG levels 3. Patient counseling and education concerning side effects of methotrexate 4. Expectant management of ectopic pregnancy

Surgical Procedures:
Laparoscopy y Salpingectomy technique o o Desiccate the tube between the uterus and the ectopic pregnancy using bipolar cautery. Compress and desiccate the tuboovarian artery, while preserving the uteroovarian artery and ligament. o o y Cut along the desiccated path, closer to the specimen, leaving a pedicle for hemostasis. Repeat until the tube is free and can be removed. Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL of isotonic sodium chloride solution [ie, normal saline or NS]; some authors use only 10 IU in 50 mL of NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension. o With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube. o o Insert the aquadissector deep into the incision. Fluid from the aquadissector, under pressure, dissects and dislodges the ectopic pregnancy and clots. o o Irrigate the bed well. If trophoblastic tissue remains, the use of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth. o o o Further dissection may damage the tube and is not usually performed. The products of conception are then removed through the 12-mm sleeve. If needed, products of conception can be reduced to smaller pieces using biopsy forceps or the aquadissector. o o o Bleeding may be controlled by applying pressure with grasping forceps for 5 minutes. Arterial bleeding may require pinpoint bipolar desiccation. Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode. o Uncontrollable bleeding may require the application of an endo loop to provide compression for 10 minutes. The ligature is then released. o y If bleeding continues, suture of the mesosalpingeal vessels may be attempted. Grasp the fimbria and rotate it to allow insertion of the aquadissector. Fimbrial evacuation technique o

Salpingotomy technique o

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o o y

Fluid under pressure dissects and dislodges the ectopic pregnancy and clots. Remove the products of conception. Perform bipolar desiccation across the tube on both sides of the ectopic pregnancy. Divide the tube at the sites of desiccation. The mesosalpinx under the ectopic pregnancy can then be either desiccated or ligated with an endo loop. Remove the products of conception.

Partial salpingectomy technique o o o

o Laparotomy y

Salpingectomy technique o Clamp the tube between the uterus and the ectopic pregnancy using a Pean or similar clamp. Cut the pedicle free and ligate the pedicle with a suture ligature. (See following image.) o

Salpingectomy technique. Shown here, the pedicle is cut free and ligated with a suture ligature. o Clamp, cut, and ligate the tuboovarian artery, while preserving the uteroovarian artery and ligament. o y Continue to clamp, cut, and ligate the mesosalpinx until the tube is free and can be removed. Infiltrate the mesosalpinx with vasopressin (20 IU in 50 mL NS). Avoid intravascular injection because it is contraindicated in patients with ischemic heart disease. It frequently causes hypertension. o With the knife or needle electrode, make a 1- to 2-cm incision on the antimesenteric side of the tube. (See following images). o Salpingotomy technique o

Salpingotomy technique. A 1- to 2-cm incision is made on the antimesenteric side of the tube using a needle electrode. o

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Salpingotomy technique. A 1- to 2-cm incision is made on the antimesenteric side of the tube using a knife.

Insert the aquadissector, or a syringe filled with saline, deep into the incision. o Fluid from the aquadissector, or syringe, under pressure, dissects and dislodges the ectopic pregnancy and clots. o Irrigate the bed well. o If trophoblastic tissue remains, the prior injection of vasopressin may lead to anoxia and death of the trophoblasts, preventing postoperative growth. o Further dissection may damage the tube and is not usually performed. o Bleeding may be controlled by applying pressure with blunt tissue forceps for 5 minutes. o Arterial bleeding may require pinpoint bipolar desiccation. o Diffuse venous bleeding is best controlled with monopolar current. A spark or arc is created using a current of 25-50 W through an electrode in noncontact mode. o Uncontrollable bleeding may require application of a suture ligature to provide compression for 10 minutes. The ligature is then released. o If bleeding continues, suture of the mesosalpingeal vessels may be attempted. o The tubal incision is left open and not repaired. Fimbrial evacuation technique o Grasp the fimbria and insert the aquadissector or a syringe filled with saline. o Fluid under pressure dissects and dislodges the ectopic pregnancy and clots. o Remove the products of conception. Partial salpingectomy technique o Place a clamp through an avascular area in the mesosalpinx under the ectopic pregnancy. This creates a space through which 2 free ties are placed. o Tie the free ties around the tube on each side of the ectopic pregnancy. o Cut free and remove the isolated portion of the tube containing the ectopic pregnancy.
o

General measures (supportive)

y

Monitoring and maintaining euvolemia (the correct amount of fluid in the body):
o o o

Monitoring urine output, BP regularly. Fluid restrict to 1 L. Diuretics (IV furosemide).

Monitoring kidney function:

o

do EUCs daily and calculating GFR.

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y y y

Treat hyperlipidemia to prevent further atherosclerosis. Prevent and treat any complications [see below] Albumin infusions are generally not used because their effect lasts only transiently.

Prophylactic anticoagulation may be appropriate in some circumstances. Specific treatment of underlying cause
y y

Immunosuppression for the glomerulonephritides (corticosteroids, ciclosporin). Standard ISKDC regime for first episode: prednisolone -60 mg/m2/day in 3 divided doses for 4 weeks followed by 40 mg/m2/day in a single dose on every alternate day for 4 weeks.

Relapses by prednisolone 2 mg/kg/day till urine becomes negative for protein. Then, 1.5 mg/kg/day for 4 weeks.
y

Frequent relapses treated by: cyclophosphamide or nitrogen mustard or ciclosporin or levamisole.

y y

Achieving better blood glucose level control if the patient is diabetic. Blood pressure control. ACE inhibitors are the drug of choice. Independent of their blood pressure lowering effect, they have been shown to decrease protein loss.

Dietary recommendations

Reduce sodium intake to 10002000 mg daily. Foods high in sodium include salt used in cooking and at the table, seasoning blends (garlic salt, Adobo, season salt, etc.) canned soups, canned vegetables containing salt, luncheon meats including turkey, ham, bologna, and salami, prepared foods, fast foods, soy sauce, ketchup, and salad dressings. On food labels, compare milligrams of sodium to calories per serving. Sodium should be less than or equal to calories per serving. Salt restriction Edema is treated by salt restriction because renal retention of sodium is one of two principal mechanisms that leads to edema in the NS. In an already edematous patient, salt restriction alone will not significantly improve edema but can reduce further accumulation of fluid. Eat a moderate amount of high protein animal food: 3-5 oz per meal (preferably lean cuts of meat, fish, and poultry) Avoid saturated fats such as butter, cheese, fried foods, fatty cuts of red meat, egg yolks, and poultry skin. Increase unsaturated fat intake, including olive oil, canola oil, peanut butter, avocadoes, fish and nuts. Eat low-fat desserts. Increase intake of fruits and vegetables. No potassium or phosphorus restriction necessary. 30

Monitor fluid intake, which includes all fluids and foods that are liquid at room temperature. Fluid management in nephrotic syndrome is tenuous, especially during an acute flare. The effects of fluid retention are managed by diuretics that force the kidney to put out more salt and water in the urine. This is helped by restricting the amount of salt in the diet and by avoiding excessive fluid intake. If a lot of fluid has been retained, it is important that diuretic therapy is carefully controlled by regular blood tests and weighing. Some patients may require to be admitted to hospital.

VII. Nursing Management

A. Actual Management

 Upon the clients admission to the hospital, the client secure consent to care. The clients temperature, pulse rate, and respiratory rate were monitored every hour, and intake and output every hour.

 Laboratory exams such as CBC with platelet count, U/A, Creatinine/TPAG and S/E was ordered.  The following drugs were also prescribed by the physician: 1. PCM 200/5 3.5 mL q 4 prn for T> 37C 2. Daily assessing of perinasal skin lesion with zinc oxide ointment. 3. Vit A 100,000 IU po today 4. Cefazolin 250 mg IVTT q 8 ( no skin test ) 5. Metronidazole 110mg IVTT ANST q 8  Client was inserted FBC  IVF D5W KVO  Client was referred to dietary for nutritional build-up and followed-up with CPTA, TPAG, Cholesterol and UTZ for liver and kidney was ordered.  PPD and nutritional rehab continued and referred accordingly.

Nursing Interventions:

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