SlideShare a Scribd company logo
1 of 94
Download to read offline
Benha University Hospital, Egypt
Aboubakr Elnashar
Definition
Implantation of the fertilized ovum outside the normal
uterine cavity.
Aboubakr Elnashar
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
Sites
Aboubakr Elnashar
>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
Aboubakr Elnashar
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
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
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
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
1. Acute Cases:
present in the emergency
room with tubal rupture
and cardiovascular
collapse
Unfortunatly it still about 20%
Aboubakr Elnashar
2. Subacute cases:
Frequently give rise to
diagnostic confusion
3. Asymptomatic cases:
suspected early in high-risk
women.
Aboubakr Elnashar
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
(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
(III) Cervical pregnancy:
In the substance of the
cervix below the level of
uterine vessels.
May cause severe vaginal
bleeding.
Aboubakr Elnashar
(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
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
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
Heterotopic ectopic pregnancy:
 Incidence:
Increased with fertility treatments reaching 1/100
 Diagnosis:
extremely difficult
50% identified after tubal rupture.
Aboubakr Elnashar
 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
 Multifetal tubal pregnancy
Twin tubal pregnancy has been reported with
both embryos in same tube as well as one
in each tube
Aboubakr Elnashar
Aboubakr Elnashar
(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
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
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
Aboubakr Elnashar
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
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
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
C. D. pouch:
Fluid with or without blood clots
Aboubakr Elnashar
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
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
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
Non cystic mass
Aboubakr Elnashar
Aboubakr Elnashar
ov
Cystic mass
Aboubakr Elnashar
Ring
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
U
Aboubakr Elnashar
Aboubakr Elnashar
Cervical pregnancy
Abdominal
pregnancy
Aboubakr Elnashar
(3) Serum Progesterone:
lower in ectopic than normal pregnancy
usually <15ng/ml.
Aboubakr Elnashar
(4) Culdocentesis:
Non-clotting blood: intraperitoneal hge.
if not: ectopic pregnancy cannot be
excluded.
Aboubakr Elnashar
(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
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
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
(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
•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
B. Intrauterine Pregnancy
Exclude by:
1-Clinical Characteristics.
2- Quantitative B sub unit HCG.
3- TVS .
4-Laparoscopy.
5-Curettage
Aboubakr Elnashar
Aboubakr Elnashar
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
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
Aboubakr Elnashar
A. Active B. Expectant
I. Surgical T. II. Medical T.
1. Laparoscopy 2.Laparotomy
Salpingectomy Salpingotomy
Systemic Local
Kim and Fox, 1999Aboubakr Elnashar
Aboubakr Elnashar
1. Laparoscopy
Indication:
Haemodynamically stable patient
(RCOG Recommendations, Grade A)
Aboubakr Elnashar
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
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
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
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
 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
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
 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
 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
1.Systemic
2. Local
Methotrexate is the drug of choice
(Cochrane library,2002).
Aboubakr Elnashar
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
 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
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
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
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
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
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
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
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
• 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
Aboubakr Elnashar
 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
 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
 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
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
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
Pregnancy of unknown location
PUL
Aboubakr Elnashar
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
Progesterone
nmol/L
>60
Viable IUP
<20
Probable
failing PUL
Repeat HCG
in 1W
Ng/ml=3.18 nmol/L
Aboubakr Elnashar
Aboubakr Elnashar

More Related Content

What's hot (20)

Obstructed labour
Obstructed labourObstructed labour
Obstructed labour
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
 
Dysfunctional labor
Dysfunctional laborDysfunctional labor
Dysfunctional labor
 
Septic Abortion
Septic AbortionSeptic Abortion
Septic Abortion
 
Rupture of the uterus
Rupture of the uterusRupture of the uterus
Rupture of the uterus
 
Molar pregnancy
Molar pregnancyMolar pregnancy
Molar pregnancy
 
Caesarean section
Caesarean sectionCaesarean section
Caesarean section
 
Obstructed Labour ppt
Obstructed Labour pptObstructed Labour ppt
Obstructed Labour ppt
 
Inversion Of Uterus
Inversion Of UterusInversion Of Uterus
Inversion Of Uterus
 
Active management of third stage labor
Active management of third stage laborActive management of third stage labor
Active management of third stage labor
 
Occipito posterior positition
Occipito posterior posititionOccipito posterior positition
Occipito posterior positition
 
Abnormal uterine contraction
Abnormal uterine contraction Abnormal uterine contraction
Abnormal uterine contraction
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Caesarean section
Caesarean sectionCaesarean section
Caesarean section
 
Management of ectopic pregnancy
Management of ectopic pregnancyManagement of ectopic pregnancy
Management of ectopic pregnancy
 
Contracted pelvis
Contracted pelvisContracted pelvis
Contracted pelvis
 
Cord Prolapse
Cord ProlapseCord Prolapse
Cord Prolapse
 
Premature labour
Premature labourPremature labour
Premature labour
 
Shoulder dystocia
Shoulder dystociaShoulder dystocia
Shoulder dystocia
 
Management of Preterm labor
 Management of Preterm labor Management of Preterm labor
Management of Preterm labor
 

Viewers also liked

Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancyarez esmail
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancydrmcbansal
 
Ectopic pregnancy BY DR SHASHWAT JANI
Ectopic pregnancy BY DR SHASHWAT JANIEctopic pregnancy BY DR SHASHWAT JANI
Ectopic pregnancy BY DR SHASHWAT JANIDR SHASHWAT JANI
 
жирэмсний аюултай шинжүүд
жирэмсний аюултай шинжүүджирэмсний аюултай шинжүүд
жирэмсний аюултай шинжүүдSosoo Byambaa
 
2.1 Цус алдалтын эмгэг эрт үе
2.1 Цус алдалтын эмгэг эрт үе2.1 Цус алдалтын эмгэг эрт үе
2.1 Цус алдалтын эмгэг эрт үеsaruul tungalag
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancyArya Anish
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancystudent
 
basics of chest X- ray interpretation
basics of chest X- ray interpretationbasics of chest X- ray interpretation
basics of chest X- ray interpretationMaha Yousif
 

Viewers also liked (13)

Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Ectopic pregnancy for undergraduate
Ectopic pregnancy for undergraduateEctopic pregnancy for undergraduate
Ectopic pregnancy for undergraduate
 
Ectopic pregnancy BY DR SHASHWAT JANI
Ectopic pregnancy BY DR SHASHWAT JANIEctopic pregnancy BY DR SHASHWAT JANI
Ectopic pregnancy BY DR SHASHWAT JANI
 
жирэмсний аюултай шинжүүд
жирэмсний аюултай шинжүүджирэмсний аюултай шинжүүд
жирэмсний аюултай шинжүүд
 
2.1 Цус алдалтын эмгэг эрт үе
2.1 Цус алдалтын эмгэг эрт үе2.1 Цус алдалтын эмгэг эрт үе
2.1 Цус алдалтын эмгэг эрт үе
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Ectopic Pregnancy
Ectopic PregnancyEctopic Pregnancy
Ectopic Pregnancy
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Chest x ray
Chest x rayChest x ray
Chest x ray
 
Chest xray
Chest xray  Chest xray
Chest xray
 
basics of chest X- ray interpretation
basics of chest X- ray interpretationbasics of chest X- ray interpretation
basics of chest X- ray interpretation
 

Similar to Ectopic pregnancy

Clinically Suspicious cervix
Clinically Suspicious cervix Clinically Suspicious cervix
Clinically Suspicious cervix Aboubakr Elnashar
 
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS           Prof. Aboubakr ElnasharART PREGNANCY COMPLICATIONS           Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr ElnasharAboubakr Elnashar
 
Ectopic Pregnancy - Obstetrical & Gynaecological Nursing
Ectopic Pregnancy - Obstetrical & Gynaecological NursingEctopic Pregnancy - Obstetrical & Gynaecological Nursing
Ectopic Pregnancy - Obstetrical & Gynaecological NursingJaice Mary Joy
 
invasive procedures for prenatal diagnosis ISUOG Guidelines
invasive procedures for prenatal diagnosis ISUOG Guidelines invasive procedures for prenatal diagnosis ISUOG Guidelines
invasive procedures for prenatal diagnosis ISUOG Guidelines Aboubakr Elnashar
 
INTRAUTERINE INSEMINATION Protocol
INTRAUTERINE INSEMINATION ProtocolINTRAUTERINE INSEMINATION Protocol
INTRAUTERINE INSEMINATION ProtocolAboubakr Elnashar
 
Management of adenxal mass during pregnancy
Management of adenxal mass during pregnancyManagement of adenxal mass during pregnancy
Management of adenxal mass during pregnancyAboubakr Elnashar
 
Emergency ultrasonography in 2nd 3rd timester
Emergency ultrasonography in 2nd 3rd timesterEmergency ultrasonography in 2nd 3rd timester
Emergency ultrasonography in 2nd 3rd timesterAboubakr Elnashar
 
ectopic pregnancy.pptx
ectopic pregnancy.pptxectopic pregnancy.pptx
ectopic pregnancy.pptxrochisha
 
OBSTETRICS EMERGENCIES
OBSTETRICS EMERGENCIESOBSTETRICS EMERGENCIES
OBSTETRICS EMERGENCIESLohith Varma
 
abortion new 1.pptx
abortion new 1.pptxabortion new 1.pptx
abortion new 1.pptxVarnamohan
 
abortion new.pptx
abortion new.pptxabortion new.pptx
abortion new.pptxVarnamohan
 

Similar to Ectopic pregnancy (20)

FIRST TRIMESTER BLEEDING
FIRST TRIMESTER BLEEDINGFIRST TRIMESTER BLEEDING
FIRST TRIMESTER BLEEDING
 
Ectopic Pregnancy
Ectopic PregnancyEctopic Pregnancy
Ectopic Pregnancy
 
Clinically Suspicious cervix
Clinically Suspicious cervix Clinically Suspicious cervix
Clinically Suspicious cervix
 
Ectopic pregnancy
Ectopic pregnancy Ectopic pregnancy
Ectopic pregnancy
 
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS           Prof. Aboubakr ElnasharART PREGNANCY COMPLICATIONS           Prof. Aboubakr Elnashar
ART PREGNANCY COMPLICATIONS Prof. Aboubakr Elnashar
 
Ectopic Pregnancy - Obstetrical & Gynaecological Nursing
Ectopic Pregnancy - Obstetrical & Gynaecological NursingEctopic Pregnancy - Obstetrical & Gynaecological Nursing
Ectopic Pregnancy - Obstetrical & Gynaecological Nursing
 
Management of infertility
Management of infertilityManagement of infertility
Management of infertility
 
Cervical pregnancy
Cervical pregnancyCervical pregnancy
Cervical pregnancy
 
invasive procedures for prenatal diagnosis ISUOG Guidelines
invasive procedures for prenatal diagnosis ISUOG Guidelines invasive procedures for prenatal diagnosis ISUOG Guidelines
invasive procedures for prenatal diagnosis ISUOG Guidelines
 
Ectop2
Ectop2Ectop2
Ectop2
 
INTRAUTERINE INSEMINATION Protocol
INTRAUTERINE INSEMINATION ProtocolINTRAUTERINE INSEMINATION Protocol
INTRAUTERINE INSEMINATION Protocol
 
Management of adenxal mass during pregnancy
Management of adenxal mass during pregnancyManagement of adenxal mass during pregnancy
Management of adenxal mass during pregnancy
 
Emergency ultrasonography in 2nd 3rd timester
Emergency ultrasonography in 2nd 3rd timesterEmergency ultrasonography in 2nd 3rd timester
Emergency ultrasonography in 2nd 3rd timester
 
ectopic pregnancy.pptx
ectopic pregnancy.pptxectopic pregnancy.pptx
ectopic pregnancy.pptx
 
OBSTETRICS EMERGENCIES
OBSTETRICS EMERGENCIESOBSTETRICS EMERGENCIES
OBSTETRICS EMERGENCIES
 
abortion new 1.pptx
abortion new 1.pptxabortion new 1.pptx
abortion new 1.pptx
 
abortion.pptx
abortion.pptxabortion.pptx
abortion.pptx
 
abortion new.pptx
abortion new.pptxabortion new.pptx
abortion new.pptx
 
abortion.pptx
abortion.pptxabortion.pptx
abortion.pptx
 
ART PREGNANCY COMPLICATIONS
ART PREGNANCY COMPLICATIONSART PREGNANCY COMPLICATIONS
ART PREGNANCY COMPLICATIONS
 

More from Aboubakr Elnashar

WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTWHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTAboubakr Elnashar
 
Adenomyosis associated infertility
Adenomyosis associated  infertilityAdenomyosis associated  infertility
Adenomyosis associated infertilityAboubakr Elnashar
 
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Aboubakr Elnashar
 
Aesthetic gynecology controversy
Aesthetic gynecology controversyAesthetic gynecology controversy
Aesthetic gynecology controversyAboubakr Elnashar
 
Hormonal assay in clinical gyn
Hormonal assay in clinical gynHormonal assay in clinical gyn
Hormonal assay in clinical gynAboubakr Elnashar
 
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineUnnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineAboubakr Elnashar
 
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationIndividualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationAboubakr Elnashar
 
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA Aboubakr Elnashar
 
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021  cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021 Aboubakr Elnashar
 
Management of pregnancy of unknown location
Management of pregnancy of unknown locationManagement of pregnancy of unknown location
Management of pregnancy of unknown locationAboubakr Elnashar
 
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021Aboubakr Elnashar
 

More from Aboubakr Elnashar (20)

WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTWHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
 
hepatitis B.pdf
hepatitis B.pdfhepatitis B.pdf
hepatitis B.pdf
 
hepatitis c2022.pdf
hepatitis c2022.pdfhepatitis c2022.pdf
hepatitis c2022.pdf
 
Adenomyosis associated infertility
Adenomyosis associated  infertilityAdenomyosis associated  infertility
Adenomyosis associated infertility
 
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
 
Adenxal mass guidelines2020
Adenxal mass guidelines2020Adenxal mass guidelines2020
Adenxal mass guidelines2020
 
Aesthetic gynecology controversy
Aesthetic gynecology controversyAesthetic gynecology controversy
Aesthetic gynecology controversy
 
Hormonal assay in clinical gyn
Hormonal assay in clinical gynHormonal assay in clinical gyn
Hormonal assay in clinical gyn
 
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVFFIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
 
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineUnnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
 
Infertility prevention
Infertility prevention Infertility prevention
Infertility prevention
 
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationIndividualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
 
Female infertility
Female infertility Female infertility
Female infertility
 
Maternal near miss
Maternal near missMaternal near miss
Maternal near miss
 
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
 
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021  cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
 
CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT  CAESAREAN SCAR DEFECT
CAESAREAN SCAR DEFECT
 
Management of pregnancy of unknown location
Management of pregnancy of unknown locationManagement of pregnancy of unknown location
Management of pregnancy of unknown location
 
Aerobic Vaginitis
Aerobic Vaginitis Aerobic Vaginitis
Aerobic Vaginitis
 
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
 

Recently uploaded

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 

Recently uploaded (20)

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 

Ectopic pregnancy

  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 63. A. Active B. Expectant I. Surgical T. II. Medical T. 1. Laparoscopy 2.Laparotomy Salpingectomy Salpingotomy Systemic Local Kim and Fox, 1999Aboubakr 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
  • 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