Dr Manal BeheryDr Manal BeheryProfessor OB&GYNEProfessor OB&GYNE

Zagazig university 2014Zagazig university 2014

ECTOPIC PREGNANCY

Ectopic:

(Ektopos) out of place

Definition Ectopic pregnancy: fertilized embryo implanted outside the uterine cavity

>95%

Classification of ectopic pregnancy

MechanicalMechanical factorsfactors CongenitalCongenital:: long narrow tube, diverticulae and accessory long narrow tube, diverticulae and accessory

ostia.ostia. TraumaticTraumatic:: operation on the tube as salpingoplasty and operation on the tube as salpingoplasty and

tubal reversal following ligation.tubal reversal following ligation. InflammatoryInflammatory:: Chronic salpingitis Chronic salpingitis NeoplasticNeoplastic:: Narrowing of the tube by a fibroid or a broad Narrowing of the tube by a fibroid or a broad

ligament tumor.ligament tumor. FunctionalFunctional:: As tubal spasm or antiperistaltic contractions. As tubal spasm or antiperistaltic contractions. endometriosisendometriosis in the tube. encourages embedding of the in the tube. encourages embedding of the

fertilized ovum.fertilized ovum.

RISK FACTORSRISK FACTORS

Hz of tubal surgeryHz of tubal surgery

Hx of STD’s (such as chlamydia)Hx of STD’s (such as chlamydia) Hx of ARTHx of ART Hx of ectopic (esp if conservatively Hx of ectopic (esp if conservatively

managed without surgery)managed without surgery) SmokingSmoking IUD in place at time of conceptionIUD in place at time of conception

Prior history of PID (pelvic inflammatory disease)

TUBAL SURGERYTUBAL SURGERY

Animation of intrauterine implantation

Pathology of Ectopic Pathology of Ectopic PregnancyPregnancy

1.1. Tubal abortionTubal abortionOutcomesOutcomes

2.2. Rupture of tubal pregnancyRupture of tubal pregnancy

Ruptured ectopic pregnancyRuptured ectopic pregnancy

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•Extraperitoneal rupture (rupture through floor of the tube)•may lead to broad ligament hematoma with death of the

ovum, or intraligamentary pregnancy.

3.3. Secondary abdominal pregnancySecondary abdominal pregnancy

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Symptoms & Signs:Symptoms & Signs:

In a woman of child bearing age with pelvi-abdominal pain and/ or vaginal bleeding …… ALWAYS….think

Amenorrhoea Amenorrhoea A dull aching painA dull aching pain is usually present in is usually present in

one iliac fossa. It is due to distension of the one iliac fossa. It is due to distension of the tube and stretching of its peritoneal coat.tube and stretching of its peritoneal coat. Classic signs –Classic signs – adnexal or cervical motion adnexal or cervical motion

tenderness.tenderness.

Clinical Finding: Undistrubed ectopic

Signs:Signs: Abdominal examinationAbdominal examination:: Tenderness in one iliac Tenderness in one iliac

fossa.fossa. Vaginal examination: Vaginal examination:

(cervical motion tenderness or jumping sign) (cervical motion tenderness or jumping sign) The cervix is soft and severe pain occurs The cervix is soft and severe pain occurs when it is moved from side to sidewhen it is moved from side to side

A mass may be felt to one side of the uterus. It A mass may be felt to one side of the uterus. It is very tender, soft and may be pulsating. is very tender, soft and may be pulsating.

SubacuteSubacute type:Symptoms: type:Symptoms: Short period of amenorrheaShort period of amenorrhea in (25%) no history in (25%) no history

of amenorrhea due to occurrence of post of amenorrhea due to occurrence of post conceptional bleeding that mistaken as a true conceptional bleeding that mistaken as a true menstrual periodmenstrual period

PainPain:: It is felt in one iliac fossa. It may be It is felt in one iliac fossa. It may be dull dull achingaching or or sharp stabbingsharp stabbing or or colickycolicky

Fainting attacks or even shockFainting attacks or even shock Vaginal bleedingVaginal bleeding occurs after pain occurs after pain

With ruptured ectopic pregnancyWith ruptured ectopic pregnancy

abdominal guarding and rigidity, abdominal guarding and rigidity, shoulder pain shoulder pain fainting attacks fainting attacks and shock.and shock.

When a woman presents with an When a woman presents with an early pregnancy…early pregnancy…

Ask yourself two questions…Ask yourself two questions…

Where is this pregnancy?Where is this pregnancy?

Is it viable?Is it viable?

Where is this pregnancy?Where is this pregnancy?

In a woman with an early pregnancy you In a woman with an early pregnancy you must determine if the pregnancy is must determine if the pregnancy is intrauterine intrauterine or an or an ectopicectopic,, because her because her life could depend on it!life could depend on it!

How to you determine location of How to you determine location of the pregnancy?the pregnancy?

First determine dating by LMPFirst determine dating by LMP Then perform ultrasoundThen perform ultrasound If you can see location of the pregnancy, you If you can see location of the pregnancy, you

are done!are done! If you cannot…it becomes more If you cannot…it becomes more

complicated…complicated…

β-hCG discriminatory valueβ-hCG discriminatory value (or zone) (or zone)

It is the lower limit of hCG at which an It is the lower limit of hCG at which an examiner can reliably visualize pregnancy examiner can reliably visualize pregnancy on ultrasound. It is 1000-2000 IU/L with on ultrasound. It is 1000-2000 IU/L with vaginal ultrasound and 5000-6000 IU/L vaginal ultrasound and 5000-6000 IU/L with abdominal ultrasound. with abdominal ultrasound.

If β-hCG levels If β-hCG levels aboveabove the the discriminatory valuediscriminatory value

The absence of uterine pregnancy The absence of uterine pregnancy signifies an abnormal pregnancy; ectopic, signifies an abnormal pregnancy; ectopic, incomplete abortionincomplete abortion

If β-hCG levels are still If β-hCG levels are still belowbelow the the discriminatory value, serial β-hCG and discriminatory value, serial β-hCG and ultrasound should be done.ultrasound should be done.

Doubling sign:Doubling sign: In normal pregnancy a 66% or greater increase In normal pregnancy a 66% or greater increase

in serum β-hCG levels should be observed in serum β-hCG levels should be observed every 48 hours (nearly doubles). every 48 hours (nearly doubles).

Inappropriately rising serum β-hCG levels Inappropriately rising serum β-hCG levels suggest (but do not diagnose) an abnormal suggest (but do not diagnose) an abnormal pregnancy including ectopic, however, they do pregnancy including ectopic, however, they do not identify its location.not identify its location.

Tran abdominal USTran abdominal US

Transvaginal ultrasound ( TVS): Transvaginal ultrasound ( TVS):

Early pregnancy with unknown Early pregnancy with unknown locationlocation

Check a serum BHCGCheck a serum BHCG If it is above the discriminatory zone (DZ)an If it is above the discriminatory zone (DZ)an

intrauterine pregnancy should be seenintrauterine pregnancy should be seen Then do an ultrasound to see if you see the Then do an ultrasound to see if you see the

pregnancypregnancy

LAPROSCOPY

Treatment of tubal pregnancyTreatment of tubal pregnancy

If the patient is shocked: If the patient is shocked: antishock measures.antishock measures. If the patient is If the patient is Rh negative Rh negative and not sensitized and not sensitized

anti-D serum is given.anti-D serum is given. Medical therapy: Medical therapy: methotrexatemethotrexate (a folic acid antagonist)(a folic acid antagonist).. IM methotrexate given as a single dose.IM methotrexate given as a single dose.

The best candidate is the woman who is The best candidate is the woman who is asymptomatic, compliant with follow-up, with asymptomatic, compliant with follow-up, with an initial serum value <5000 IU/L.an initial serum value <5000 IU/L. Contraindications:Contraindications:

BreastfeedingBreastfeeding Immunodeficiency / active infectionImmunodeficiency / active infection Chronic liver diseaseChronic liver disease Active pulmonary diseaseActive pulmonary disease Active peptic ulcer or colitisActive peptic ulcer or colitis Blood disorderBlood disorder Hepatic, Renal or Haematological Hepatic, Renal or Haematological

dysfunctiondysfunction

Significantly worsening abdominal pain, Significantly worsening abdominal pain,

Haemodynamic instabilityHaemodynamic instability

Level of HCG do not decline by at least 15% Level of HCG do not decline by at least 15% between Day 4 & 7 post treatmentbetween Day 4 & 7 post treatment

or plateauing HCG level after first week of or plateauing HCG level after first week of treatmenttreatment

Signs and Treatment failure and tubal rupture:

Follow-Up:Follow-Up: If the β-hCG level does not decline (plateau or If the β-hCG level does not decline (plateau or

increase), the patient may require either a increase), the patient may require either a second dose of methotrexate or surgery.second dose of methotrexate or surgery.Surgical management:Surgical management: Laparoscopy approach – salpingostomyLaparoscopy approach – salpingostomy

Laprotomy – salpingostomy Laprotomy – salpingostomy salpingectomysalpingectomy

Salpingostomy / Salpingotomy is only indicated when:

1. The patient desires to conserve her fertility

2. Patient is haemodinmically stable

3. Tubal pregnancy is accessible

4. Unruptured and < 4Cm. In size5. Contralateral tube is absent or damaged

•Segmental resection: removal of a portion of the affected tube.

laparatomy (if the mass is greater than 3.5 cm in diametar, internal bleeding, cardiovascular colapse)

Treatment:Treatment:-metotrexate (if the mass is less then 3.5 cm in diametar)-laparascopy,or Laprotomy

SALPINGOSTOMY SALPINGECTOMY Removal of any pelvic hematomas or Removal of any pelvic hematomas or intrapertoneal blood then peritoneal toilet. intrapertoneal blood then peritoneal toilet.

Algorithm for the diagnosis of unruptured ectopic pregnancy without laparoscopy.

11- Positive pregnancy test

Lowe abdominal pain +Minimal Vaginal bleeding

Asymptomatic with factorsfor ectopic pregnancy

2. History + clinical examination

Management of ectopic pregnancy

If sure of date of LMP and /or Regular cycle, i.e. >6 wks. gestation,

Arrange TV ultrasound

If unsure of date of LMP and /or irregular cycle,Measure serum hCG

If hCG <1000 (?early Intrauterine/? Ectopic pregnancy

If Hcg >1000, useprotocol forsuspected

Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000

Meet criteria for Methorexate treatment

Does not meet criteria for methotrexate treatment

Use methotrexateprotocol

Laproscopic /salpingotomy/Salpingectomy ?Proceed to

laparotomy OR Laparotomy if haemodynamically unstable

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Thank you