Ectopic Pregnancy

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Ectopic Pregnancy

• Dr.Najwa.B.Eljabu
• Arab Libyan Board
• Msc reproductive and Maternal sciences
• Glasgow University

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Definition

• Ectopic pregnancy is implantation occurring
  outside the uterine cavity.
• Either implanted outside the uterus (fallopian
  tube, ovary and abdominal cavity) or in abnormal
  position within the uterus (cornua, cervix).
• Combined tubal and uterine (Heterotopic)
  pregnancies are uncommon)
• It is a major cause of maternal mortality in the
  first trimester.

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Overview

• Incidence Increasing (16/1000 Pregnancies in UK)
• 95-98 tubal
• 50 ampulla
• 20 isthmus
• 12 fimbrial
• 10 interstitial
• Mortality Decreasing With Better Detection
• Surgical and Medical Treatment Available
• Recurrence Rate 10-15

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Risk Factors

• Maternal age
• Number of sexual partners
• Cigarette smoking
• Previous Ectopic Pregnancy
• PID (Gonorrhea, Chlamydia)
• Tubal Surgery or pelvic surgery
• Infertility and infertility treatment
• ICUD
• IVF

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Sites

• Ampulla (50)
• Isthmus (20)
• Cornua (lt 2)
• Ovary (lt 2)
• Abdomen (lt 2)
• Cervix (lt 2)

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• Simultaneous intrauterine and ectopic pregnancies
  (heterotopics) occur in 1/3000 to 1/30000
  pregnancies

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Symptoms

• Amenorrhea (typically 6-8 weeks)
• Abdominal Pain
• Vaginal Bleeding (small amount)
• Syncope
• Pelvic Mass
• Shoulder tip pain

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• 15 of the cases present acutely with abdominal
  pain, amenorrhea and haemodynamic compromise
• In most cases the history will be more chronic
• Arias-stella reaction

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Evaluation and Diagnosis

• History and Physical Exam
• Blood investigations (CBC, blood group)
• Serial Quantitative HCG
• Ultrasound
• Laparoscopy

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Evaluation and Diagnosis

• Clinical
• O/E look for signs of intra-peritoneal
  hemorrhage
• Abdominal tenderness(95)
• Peritonism
• Abdominal distension
• Pain on movement of the cervix (cervical
  excitation (50)
• Adnexal mass (63)
• Cervix ----closed

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Serial B-HCG

• HCG Levels Double Every 48 Hrs
• 66 Rise / 48 Hrs Consistent With Ectopic
• Single Determination Not Helpful
• Best If Done Within Same Laboratory
• At HCG of 1000 IU/L gestational sac of an
  intrauterine pregnancy should be detected by US

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Ultrasound

• May or May Not Be Helpful
• Discriminatory Zone
• TV 1500-2000 mIU/ml
• TA 6500 mIU/ml
• IUP Generally Excludes Ectopic
• Free fluids in POD
• Adnexal mass

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Treatment

• Observation
• Laparoscopy
• Laparotomy
• Medical
• MTX
• Hyperosmolar Glucose
• PG

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Observation

• Many Tubal Pregnancies Abort
• Needs simple follow up
• Criteria for selection of patients
• Serial HCG levels and US

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Management of acute hemorrhage

• Urgent hospital assessment
• Resuscitation
• Intravenous access and two large cannula
• Start IVF (colloid)
• Send for blood group, CBC and cross match
• Serum BHCG
• Transfer to theater
• Anti D should be given to all RH negative women

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Laparoscopy

• Allows Diagnosis and Treatment
• Lower post op morbidity and quicker recovery
• Salpingotomy
• Salpingectomy (Total / Partial)
• Cornual Resection
• Minimally Invasive, Unlike Laparotomy
• Few Contraindications Unstable Patient (Possibly)

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Mini-laparotomy

• Salpingectomy
• Salpingotomy
• Needed in acute intra-peritoneal
  haemorrhage-------for immediate ligation of the
  bleeding point

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Medical treatment

• Suitable patients are
• Haemodynamically stable
• serum BHCG less than 10000IU/L
• no extrauterine fetal heart by US
• compliant patient

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Methotrexate

• Toxic to Trophoblast Cells
• Minimal Side Effects
• May Preserve Fertility in Cases of Cervical
  Pregnancy
• Requires Compliant Patient, Time
• Pain Not Uncommon
• BHCG May Rise Initially

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Persistent Trophoblast

• Most Often after Salpingostomy
• Laparoscopic
• Minilap
• Most Easily Treated With MTX

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Outcomes

• 15 Repeat Ectopic Rate
• 60-70 intra-uterine pregnancy after single
  ectopic

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Summary

• Ectopic Pregnancy is a Common, Treatable Problem
• Sensitive Assays Allow Early Detection
• Surgical and Medical Options Exist
• Ruptured Ectopics should be Unusual with
  Compliant Patients and Appropriate Medical Care

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Thanks