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Ectopic pregnancy
Ectopic pregnancy
Ectopic pregnancy
Ectopic pregnancy
Ectopic pregnancy
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Ectopic pregnancy

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Ectopic pregnancy

Ectopic pregnancy

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  • 1. Benha University Hospital, Egypt Aboubakr Elnashar
  • 2. Definition Implantation of the fertilized ovum outside the normal uterine cavity. Aboubakr Elnashar
  • 3. Incidence Increased dramatically in the past few decades 1970: 4.5/1,000 pregnancies 1992: 19.7/ 1,000 pregnancies From 1947 to1967: only 8.5% of EPs were diagnosed before rupture (Breen, 1970) Aboubakr Elnashar
  • 4. Sites Aboubakr Elnashar
  • 5. >95% tubal  80% ampullary  12% isthmical  5% fimbrial  2% cornual < 5% extratubal  1.4% abdominal  2% cervical and ovarian each or rudimentary horn Aboubakr Elnashar
  • 6. Aboubakr Elnashar
  • 7. Risk factors (Meta- analyses: Ankum et al 1996; Mol et al 1997& Skjeldestad 1998) Risk Factor Relative Risk (Fold) 1-Tubal surgery 21.0 2-Tubal Sterilization 9.3 3-Previous Ectopic 8.0 4-Previous Salpingitis 6.0 5-DES Exposure 5.0 6-Contraceptive 4.5 7-Assisted reproduction 4.0 Aboubakr Elnashar
  • 8. Ectopic pregnancy/1000 Woman- Years (Sivin &Steren,1994) All U.S. women 1.50 Noncontraceptive users 3.00 Copper T-380 IUD 0.20 Progesterone IUD 6.80 Levonorgestrel IUD 0.20 Norplant 0.28 So Tcu-380A and the Levonorgestrel IUD are acceptable choices for women with previous ectopic pregnancies. Aboubakr Elnashar
  • 9. ART increase the incidence of tubal & heterotopic pregnancy. Heterotypic pregnancy: was 1/ 30,000 now 1/7000. After superovulation or ART: 1/ 100- 900 (Savare et al ,1993) Aboubakr Elnashar
  • 10. Clinical presentation Symptoms  Abdominal pain 95%  Amenorrhoea 80%  Vaginal bleeding 70%  Pregnancy sympt 20%  Dizziness or syncope 50%  Gastrointestinal sym 80% The most important sign is abdominal pain Signs  Adnexal tender 80%  Abd. tender 90%  Adnexal mass 50%  Uterine enlarg 25%  Fever 5% The most important sign is adnexal tenderness that is aggravated by moving the cervix sideways (cervical excitation). Aboubakr Elnashar
  • 11. 1. Acute Cases: present in the emergency room with tubal rupture and cardiovascular collapse Unfortunatly it still about 20% Aboubakr Elnashar
  • 12. 2. Subacute cases: Frequently give rise to diagnostic confusion 3. Asymptomatic cases: suspected early in high-risk women. Aboubakr Elnashar
  • 13. Uncommon Sites of Ectopic Pregnancy (I) Cornual angular pregnancy:  Implantation in the interstitial portion of the tube.  Uncommon but dangerous {when rupture occurs bleeding is severe and disruption is extensive that it needs hysterectomy}. Aboubakr Elnashar
  • 14. (II) Pregnancy in a rudimentary horn: In the blind rudimentary horn of a bicornuate uterus. {horn is capable of some hypertrophy and distension}, rupture usually does not occur before 16-20 ws. Aboubakr Elnashar
  • 15. (III) Cervical pregnancy: In the substance of the cervix below the level of uterine vessels. May cause severe vaginal bleeding. Aboubakr Elnashar
  • 16. (IV) Ovarian pregnancy:  Etiology: 1. Pelvic adhesions. 2. Ovarian endometriosis.  Pathogenesis:  Fertilization of the ovum inside the ovary or ,  Implantation of the fertilized ovum in the ovary.  Spiegelberg criteria: 1. Gestational sac located in the region of the ovary, attached to the uterus by the ovarian ligament, Its wall contain ovarian tissue 2. The tube on the involved side is intact.Aboubakr Elnashar
  • 17. V) Abdominal pregnancy: 1. Primary: in the peritoneal cavity from the start. 2. Secondary: after tubal rupture or abortion. 3. Intraligamentous pregnancy: abdominal but extraperitoneal, between the anterior and posterior leaves of the broad ligament after rupture of tubal pregnancy in the mesosalpingeal border. Aboubakr Elnashar
  • 18. Treatment: 1. fetus removed 2. cord severed close to placenta 3. membrane trimmed. 4. Placenta removed only if attached to removable structures e.g omentum otherwise it is left in place & methotrexate therapy is given postoperative to hasten placental involution (controversial) 5. Arterial embolization: embolization for specific bleeding sites Aboubakr Elnashar
  • 19. Heterotopic ectopic pregnancy:  Incidence: Increased with fertility treatments reaching 1/100  Diagnosis: extremely difficult 50% identified after tubal rupture. Aboubakr Elnashar
  • 20.  Should be considered: 1. After ART 2. Persistent or rising HCG levels after D & C for spontaneous or induced abortion 3.uterine fundus > menstrual date 4. more than one corpus luteum 5. Absence of vaginal bleeding in presence of S& S of ectopic pregnancy 6. Ultrasound evidence of uterine & extrauterine pregnancy  Treatment: If retention of the intrauterine gestation is desired, the ectopic pregnancy must be treated surgically. Aboubakr Elnashar
  • 21.  Multifetal tubal pregnancy Twin tubal pregnancy has been reported with both embryos in same tube as well as one in each tube Aboubakr Elnashar
  • 22. Aboubakr Elnashar
  • 23. (1) Serum ß hCG:  Urine pregnancy tests are positive in only 50-60% of ectopic.  Serum ß hCG:  more sensitive  can detect very early pregnancy about 10 days after fertilization i.e. before the missed period.  Detection level: 25 mu/Ml  Negative test: exclude EP in > 98% of cases.  Useful in:- 1. Acute cases 2. Sub acute (D.D. of extra-uterine causes) (Barnes etal, 1985; Cartwrighte et al, 1986; Kim and Fox; 1999)Aboubakr Elnashar
  • 24. Quantitative ß sub HCG Detection Level= 5 mIU/mL •Discriminatory zone: TVS: 1500-2000 mIU/mL TAS: 6000 mIU/mL •Empty uterus + HCG >1500mu/mL= 100% ectopic (Barnhart et al,1994) Aboubakr Elnashar
  • 25. Doubling time:  Normal pregnancy: ß hCG level is doubling/48 h during the first 42 days of gestation.  Ectopic pregnancy: ß hCG level usually shows <66% increase within 48 h. This is not specific to ectopic pregnancy  15% of normal pregnancies as well as in abortions: Unfortunately, there is also slow doubling time. Aboubakr Elnashar
  • 26. Aboubakr Elnashar
  • 27. 2. Ultrasonography A.Uterine 1. No IU gestational sac 2. Pseudogestational sac (a fluid collection or debris in the cavity) 10-20% of Ectopic P. No double decidual sac sign No yolk sac or embryo Not eccentric (within the cavity) 3. No yolk sac in a G. sac > 20 mm Aboubakr Elnashar
  • 28. B. Adnexal 1. Non cystic mass: (Blob sign) inhomogeneous small mass next to the ovary with no sac or embryo. By pressing the vaginal probe gently against the ectopic it moves separately to the ovary. The most appropriate sign. Sensitivity 84% & specificity 99% Aboubakr Elnashar
  • 29. 2. Cystic mass: 3. Ring: (Bagel sign) hyperechoic ring around the gestational sac 4.Sac & embryo. Ipsilateral side: Corpus luteum: 85% of cases Aboubakr Elnashar
  • 30. C. D. pouch: Fluid with or without blood clots Aboubakr Elnashar
  • 31. Discriminatory zones:  Diagnosis of ectopic pregnancy is made if there is: 1. An empty uterine cavity by TAS with ß hCG > 6000 mIU/ml. 2. An empty uterine cavity by TVS with ß hCG >1500- 2000 mIU/ml. Aboubakr Elnashar
  • 32. TVS Versus TAS 1-IUG sac can be excluded 1-2 w earlier than TAS. 2. Discrimination Zone is (1500 Vs 6000 mu/ml) 3-More ability to detect the adnexal mass 4- Early detection of cardiac activity . 5- More ability to dd true from pseudo-sac Aboubakr Elnashar
  • 33. True sac False sac Uterine: Double Decidual Sac Sign: Two concentric reflective rings The outer is the reflective ring of decidua vera The inner is the reflective ring of combination of chorion & decidua capsularis Aboubakr Elnashar
  • 34. Non cystic mass Aboubakr Elnashar
  • 35. Aboubakr Elnashar
  • 36. ov Cystic mass Aboubakr Elnashar
  • 37. Ring Aboubakr Elnashar
  • 38. Aboubakr Elnashar
  • 39. Aboubakr Elnashar
  • 40. U Aboubakr Elnashar
  • 41. Aboubakr Elnashar
  • 42. Cervical pregnancy Abdominal pregnancy Aboubakr Elnashar
  • 43. (3) Serum Progesterone: lower in ectopic than normal pregnancy usually <15ng/ml. Aboubakr Elnashar
  • 44. (4) Culdocentesis: Non-clotting blood: intraperitoneal hge. if not: ectopic pregnancy cannot be excluded. Aboubakr Elnashar
  • 45. (5) Curettage:  Helpful when: HCG < 2000 mU/mL & non-rising (Stovell et al ,1992) 1. IU abortion: decidua & chorionic villi. 2. Ectopic: Decidua only or Arias Stella reaction in the endometrium as well cellular atypism, mitotic activity and glandular proliferation 3. IU complete abortion: Decidua only Aboubakr Elnashar
  • 46. 6. Laparoscopy The need decreased after the use of B-HCG & TVS (Speroff et al, 1999) Indications: 1-Definite diagnosis if there is doubt 2-Concurrent operative Laparoscopy 3-Local injection of chemotherapeutics Aboubakr Elnashar
  • 47. Aboubakr Elnashar
  • 48. Aboubakr Elnashar
  • 49. Aboubakr Elnashar
  • 50. Aboubakr Elnashar
  • 51. Aboubakr Elnashar
  • 52. Aboubakr Elnashar
  • 53. Aboubakr Elnashar
  • 54. Aboubakr Elnashar
  • 55. Aboubakr Elnashar
  • 56. (7) CBC:  Hgb & hct: assess anemia.  Leucocytic count: exclude infections as appendicitis & salpingitis. (8) Special investigation: (abdominal pregnancy)  MRI: preoperative detection of placental anatomic relationships  Plain X-ray: shows abnormal lie. In lateral view the fetus overshadows the maternal spines Aboubakr Elnashar
  • 57. •Ruptured ovarian cyst. •Bleeding corpus L. •Adnexal torsion. • Endometriosis. •Salpingitis . Differential Diagnosis A. Extra uterine causes of Acute Abdominal Pain All can be exclude by: 1-Clinical Characteristics 2-B sub unite Qualitative HCG 25 mu / ml . •Diverticulitis •Appendicitis. •Mesenteric lymphadenitis •Acute gastroenteritis •Acute cholecystitis •Perforated ulcer •Acute pancreatitis •Intestinal obstruction •Ureteral calculus •Pyelonephritis Aboubakr Elnashar
  • 58. B. Intrauterine Pregnancy Exclude by: 1-Clinical Characteristics. 2- Quantitative B sub unit HCG. 3- TVS . 4-Laparoscopy. 5-Curettage Aboubakr Elnashar
  • 59. Aboubakr Elnashar
  • 60. S. BHCG levcl Mu/mL <2000 >2000 Ectopic PRepeat in 2-3 D Abnormal rise Normal rise IUP Active management Suspected Ectopic Pregnancy Positive B Qualitative B-HCG 25mu/Ml No Sac TVS IUP Extr UP Active manageme nt B HCG level mu/ml Aboubakr Elnashar
  • 61. Failed IUP Decreasing Villi identified No Villi Rising or plateauing FollowHCG until negative Repeat HCG in 2-3 D Expectant Active management Suspected Ectopic Pregnancy Cont. Uterine Curettage Abnormal S. B HCG rise Laparoscopy >2000Mu/mL<2000Mu/mL Aboubakr Elnashar
  • 62. Aboubakr Elnashar
  • 63. A. Active B. Expectant I. Surgical T. II. Medical T. 1. Laparoscopy 2.Laparotomy Salpingectomy Salpingotomy Systemic Local Kim and Fox, 1999Aboubakr Elnashar
  • 64. Aboubakr Elnashar
  • 65. 1. Laparoscopy Indication: Haemodynamically stable patient (RCOG Recommendations, Grade A) Aboubakr Elnashar
  • 66. laparoscopic surgery appears to be the tt of choice (Cochrane library,2002). • Compared to open surgery, laparoscopic conservative surgery was: *less successful in the elimination of tubal pregnancy {higher persistence of trophoblast} *Safe *comparable intrauterine pregnancy *less costly *lower repeat ectopic pregnancy rate.Aboubakr Elnashar
  • 67. A. Salpingectomy: Indications : 1. Childbearing completed. 2. Second ectopic pregnancy in the same tube. 3. Uncontrolled bleeding. 4. Severely damaged tube (Kim and Fox,1999) . In the presence of a healthy contralateral tube there is no clear evidence that salpingotomy should be used in preference to salpingectomy (RCOG Recommendations May 2004 “Grade B”) Aboubakr Elnashar
  • 68. Indications (RCOG Recommendations,2004 Grade B) Contralateral tubal disease and desire for future fertility. Women must be made aware of the risk of a further ectopic pregnancy. Aboubakr Elnashar
  • 69. B. Salpingotomy Not preferable: *IU pregnancy rates were similar (salpingotomy 60% vs 54%) *1. Trend toward lower repeat ectopic pregnancy rates (salpingeotomy 18% vs 8%). 2. Trend towards higher rates of persistent trophoblast (RCOG May 2004, Evidence level IIa) Aboubakr Elnashar
  • 70.  Operative Complications: Bleeding from Fallopian Tube  Occurs during: salpingotomy or extraction of ectopic pregnancy.  Prevention:  Careful manipulations.  Injection of petrissin in the mesosalpinx.  Treatment: Grasping the bleeding point for 5 m with raising of the tube to kink blood flow Bipolar coagulation or endocoagulation of bleeding point Laparoscopic salpingectomy. Aboubakr Elnashar
  • 71. Indications (Kim and Fox, 1999) * Hemodynamical unstability. * Laparoscopic contraindication: obesity or severe adhesions * Surgeon is not trained in laparoscopic surgery * Necessary laparoscopic equipment is not available 2. Laparotomy Aboubakr Elnashar
  • 72.  Persistent Trophoblast  Incidence (Graczykowski and Mishell 1997): 5% after laparotomy 10% after laparoscopy 15% after Salpingostomy  Factors that increasing the risk: 1. Higher preoperative serum hCG levels (>3000 iu/l 2. Rapid preoperative rise in serum hCG 3. The presence of active tubal bleeding (RCOG May 2004 Evidence level IV)  Prophylaxis: Single dose Methot 1mg/kg Aboubakr Elnashar
  • 73.  Prophylactic Methotrexate: (Gracia et al,2002)  single dose 1 mg/kg after laparoscopic salpingostomy:  Reduce risk of tubal rupture by 90%, need for additional surgery by 60%, costs by 46%. Aboubakr Elnashar
  • 74. 1.Systemic 2. Local Methotrexate is the drug of choice (Cochrane library,2002). Aboubakr Elnashar
  • 75. Indications of medical treatment: (Stovall et al 1991,, Gross et al 1995& Alito et al 1999) 1. The Patient: hemodynamically stable. Healthy (SGOPT<50U, creatinine <1.3 mg/ml& WBC >3000mm3) 2. U/S: Gestational sac <4 cm No intrauterine pregnancy. No evidence of rupture (haemoperitoneum) No fetal cardiac activity 3. HCG: < 10,000 IU/mL. Best results when <3,000 (RCOG,2004)Aboubakr Elnashar
  • 76.  Women should be given clear information (preferably written) about the possible need for further treatment & adverse effects following treatment.  Women should be able to return easily for assessment at any time during follow-up (RCOG, Grade B) Aboubakr Elnashar
  • 77. 1. Systemic: A. Single-dose (50 mg/m2) I.M. In UK • The most widely used medical tt • Serum hCG: checked on days 4 & 7 • Further dose: if hCG failed to fall by > 15% • Surface area: 4wt+7/wt+90 or from table • Results: Success rate: 80-90% (Lipscomb et al, 1998; Morlock, 2000). 15%: require more than one dose . 10%: require surgical intervention. • cost-effective (Lecuru et al, 2000; Morlock, 2000) • Side effect: <1 % (Speroff, 1999) Aboubakr Elnashar
  • 78. B. Multi-dose Protocol: In USA 1 mg/kg on days 1,3,& 5 with folonic acid rescue on days 2,4 & 6 Aboubakr Elnashar
  • 79. Methotrexate in a single dose IM is not effective enough to advocate its routine use (Cochrane library,2002). •Additional injections for inadequately declining serum hCG concentrations are frequently necessary. Aboubakr Elnashar
  • 80. Document tubal gestation as defined by BhCG &T.V.S. I. Ensure the following criteria are met: BhCG <10,000 mIu/ml Tubal diameter <3.5 cm Absence of fetal heart II. Inform the patient about: Alternative therapeutic options Possible side effect Risk of treatment failure Prospect of future fertility III. If medical treatment is chosen: Day 1: FBC, LFT, KFT, If Rh – Ve, Anti D Do not start medical treatment if unsatisfactory If BhCG <5,000 mIu/ml Single dose methotrexate regimen If BhCG >5,000 mIu/Ml Two doses methotrexate regimen IV. On discharge: Inform patient: If abd pain {as the pregnancy resolves}: simple analgesia Avoid intercourse until follow is complete Contraception for 3 ms. Avoid herbal remedies &vit preparation containing folate. Contact ER if concerns regarding pain or bleeding. Aboubakr Elnashar
  • 81. Single dose methotrexate regimen: Day 1: Methotrexate 50 mg/m2 I.M. Day 4: BhCG Day 7: FBC, BhCG, LFT, KFT D14: FBC, BhCG Weekly BhCG unitl BhCG <25 mIu/ml If BhCG doesn’t fall by more than 15% between D4 – D7 administer 2nd dose If 2nd dose is administered: Day 7: have NL LFT, injection should be given in opposite gluteal. Day 11: BhCG Day 14: FBC, BhCG, LFT, KFT Aboubakr Elnashar
  • 82. Two doses methotrexate regimen: Day 1: Methotrexate 50 mg / m2 IM Day 4: Methotrexate 50 mg / m2 IM other gluteal BhCG Day 7: BhCG, FBC, LFT, KFT Weekly BhCG until BhCG <25 mIu/ml If BhCG doesn’t fall by more than 15% between day 4 – day 7 administer Methotrexate on day 7 and day 11 Day 11: BhCG Day 14: BhCG, LFT, KFT, FBC Aboubakr Elnashar
  • 83. 2. Local: A. Laparoscopic B. Transvaginal There is no place for local methotrexate under laparoscopic guidance (Cochrane library,2002): 1.less effective than laparoscopic salpingostomy in the elimination of tubal pregnancy. 2. The risks of anesthesia and trocar insertion Aboubakr Elnashar
  • 84. • Compared to laparoscopic adminstration of methotrexate, transvaginal administration of methotrexate under sonographic guidance is: 1- less invasive and 2- More effective 3- Requires visualization of an ectopic gestational sac and specific skills and expertise of the clinician. Aboubakr Elnashar
  • 85. Aboubakr Elnashar
  • 86.  Indications (RCOG, 2004 Grade C) 1. Patient: Clinically stable or asymptomatic 2. US: Unruptured mass <4 cm 3. HCG: Initially < 1000 iu/l Decreasing level  Clear information (preferably written) about the importance of compliance with follow-up  Should be within easy access to the hospital treating them. Aboubakr Elnashar
  • 87.  Follow up: 1. HCG: Twice weekly (< 50% of its initial level within 7d) Then weekly until < 20 iu/l 2. TVS: weekly (reduction in the size) .  Indication of active intervention (RCOG 2004)  If symptoms of ectopic pregnancy occur  Serum hCG levels rise above 1000 iu/l  Levels start to plateau. Aboubakr Elnashar
  • 88.  Results:  25% can be managed expectantly.  70% of this will avoid surgery (Ylostalo et al, 1992; Speroff et al, 1999) The long term outcome is similar to that with active treatment (Rantala/Makinen, 1997). Aboubakr Elnashar
  • 89. The 18- month cumulative rate of IU Pregnancy (Bouyer et al 2000) Salpingectomy * 57 Salpingostomy Salpingotomy Methotrexate (systemic) % of IUP }* 73 80 P < 0.01 * Pregnancy was very similar if there is no fertility factor Aboubakr Elnashar
  • 90. Anti-D immunoglobulin (RCOG,2004 Grade B) Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D (50 µg) Aboubakr Elnashar
  • 91. Pregnancy of unknown location PUL Aboubakr Elnashar
  • 92. HCG <1500 Repeat 48H <35% Probable E Laparoscopy <53% Possible E serial HCG / TVS until diagnosis made or HCG reach <15 IU/L >53% Possible IUP US in 2W >1500 Probable E Laparoscopy Aboubakr Elnashar
  • 93. Progesterone nmol/L >60 Viable IUP <20 Probable failing PUL Repeat HCG in 1W Ng/ml=3.18 nmol/L Aboubakr Elnashar
  • 94. Aboubakr Elnashar

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