Published on March 9, 2014
ECTOPIC PREGNANCY Dr Manal Behery Professor OB&GYNE Zagazig university 2014
Ectopic : (Ektopos) out of place Definition Ectopic pregnancy: fertilized embryo implanted outside the uterine cavity
Classification of ectopic pregnancy >95%
Mechanical factors Congenital: long narrow tube, diverticulae and accessory ostia. Traumatic: operation on the tube as salpingoplasty and tubal reversal following ligation. Inflammatory: Chronic salpingitis Neoplastic: Narrowing of the tube by a fibroid or a broad ligament tumor. Functional: As tubal spasm or antiperistaltic contractions. endometriosis in the tube. encourages embedding of the fertilized ovum.
RISK FACTORS Hz of tubal surgery Hx of STD’s (such as chlamydia) Hx of ART Hx of ectopic (esp if conservatively managed without surgery) Smoking IUD in place at time of conception
Prior history of PID (pelvic inflammatory disease)
Animation of intrauterine implantation
P athology of E ctopic P regnancy
Outcomes 1. Tubal abortion
2. Rupture of tubal pregnancy
Ruptured ectopic pregnancy
•Extraperitoneal rupture (rupture through floor of the tube) •may lead to broad ligament hematoma with death of the ovum, or intraligamentary pregnancy. 17 WWW.SMSO.NET
3. Secondary abdominal pregnancy
Symptoms & Signs: In a woman of child bearing age with pelvi-abdominal pain and/ or vaginal bleeding …… ALWAYS….think
Clinical Finding: Undistrubed ectopic Amenorrhoea A dull aching pain is usually present in one iliac fossa. It is due to distension of the tube and stretching of its peritoneal coat. Classic signs – adnexal or cervical motion tenderness.
Signs: Abdominal examination: Tenderness in one iliac fossa. Vaginal examination: (cervical motion tenderness or jumping sign) The cervix is soft and severe pain occurs when it is moved from side to side A mass may be felt to one side of the uterus. It is very tender, soft and may be pulsating.
Subacute type:Symptoms: Short period of amenorrhea in (25%) no history of amenorrhea due to occurrence of post conceptional bleeding that mistaken as a true menstrual period Pain: It is felt in one iliac fossa. It may be dull aching or sharp stabbing or colicky Fainting attacks or even shock Vaginal bleeding occurs after pain
With ruptured ectopic pregnancy abdominal guarding and rigidity, shoulder pain fainting attacks and shock.
When a woman presents with an early pregnancy… Ask yourself two questions… Where is this pregnancy? Is it viable?
Where is this pregnancy? In a woman with an early pregnancy you must determine if the pregnancy is intrauterine or an ectopic, because her life could depend on it!
How to you determine location of the pregnancy? First determine dating by LMP Then perform ultrasound If you can see location of the pregnancy, you are done! If you cannot…it becomes more complicated…
β-hCG discriminatory value (or zone) It is the lower limit of hCG at which an examiner can reliably visualize pregnancy on ultrasound. It is 1000-2000 IU/L with vaginal ultrasound and 5000-6000 IU/L with abdominal ultrasound.
If β-hCG levels above the discriminatory value The absence of uterine pregnancy signifies an abnormal pregnancy; ectopic, incomplete abortion If β-hCG levels are still below the discriminatory value, serial β-hCG and ultrasound should be done.
Doubling sign: In normal pregnancy a 66% or greater increase in serum β-hCG levels should be observed every 48 hours (nearly doubles). Inappropriately rising serum β-hCG levels suggest (but do not diagnose) an abnormal pregnancy including ectopic, however, they do not identify its location.
Tran abdominal US
Transvaginal ultrasound ( TVS):
Early pregnancy with unknown location Check a serum BHCG If it is above the discriminatory zone (DZ)an intrauterine pregnancy should be seen Then do an ultrasound to see if you see the pregnancy
Treatment of tubal pregnancy If the patient is shocked: antishock measures. If the patient is Rh negative and not sensitized anti-D serum is given. Medical therapy: methotrexate (a folic acid antagonist). IM methotrexate given as a single dose.
The best candidate is the woman who is asymptomatic, compliant with follow-up, with an initial serum value <5000 IU/L. Contraindications: Breastfeeding Immunodeficiency / active infection Chronic liver disease Active pulmonary disease Active peptic ulcer or colitis Blood disorder Hepatic, Renal or Haematological dysfunction
Signs and Treatment failure and tubal rupture: Significantly worsening abdominal pain, Haemodynamic instability Level of HCG do not decline by at least 15% between Day 4 & 7 post treatment or plateauing HCG level after first week of treatment
Follow-Up: If the β-hCG level does not decline (plateau or increase), the patient may require either a second dose of methotrexate or surgery. Surgical management: Laparoscopy approach – salpingostomy Laprotomy – salpingostomy salpingectomy
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 size 5. 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: -metotrexate (if the mass is less then 3.5 cm in diametar) -laparascopy,or Laprotomy SALPINGOSTOMY SALPINGECTOMY intrapertoneal blood then peritoneal toilet. Removal of any pelvic hematomas or
Algorithm for the diagnosis of unruptured ectopic pregnancy without laparoscopy.
Management of ectopic pregnancy 11- Positive pregnancy test Lowe abdominal pain + Minimal Vaginal bleeding Asymptomatic with factors for ectopic pregnancy 2. History + clinical examination
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, use protocol for suspected Ectopic pregnancy 3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000 Meet criteria for Methorexate treatment Use methotrexate protocol Does not meet criteria for methotrexate treatment Laproscopic /salpingotomy/ Salpingectomy ?Proceed to laparotomy OR Laparotomy if haemodynamically unstable
Thank you 47 WWW.SMSO.NET
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