Management of tubal ectopic pregnancy

Management of ectopic pregnancy
Dr.V.Ravimohan

Incidence 11.1/1000 pregnancies
Treatment options
1.Expectant
2.Medical
3.Surgical

Ruptured ectopic with collapse
Get help- call senior SPR/Consultant on call and anaesthetist
ABC of resuscitation
give facial oxygen
Site two IV lines (at least 16g), commence IV fluids (crystalloid)
Send blood for FBC, Clotting screen and cross-match at least 4 units of blood.
insert indwelling catheter
arrange theatre for laparotomy
whilst awaiting transfer to theatre continue fluid resuscitation and ensure intensive monitoring of haemodynamic state
do not wait for BP and pulse to normalise prior to transfer-resuscitation and surgery need to go hand in hand.
Pfannensteil incision, locate tube directly and clamp
salpingectomy and wash out of abdomen
assess bloods consider CVP / HDU discuss with anaesthetist
record operative findings including the state of the remaining tube/pelvis
Anti – D immunoglobulin (250 IU)to be given to Rhesus negative women

Surgical Management

Salpingectomy Vs Salpingotomy
No randomised controlled studies available
Evidence from observational studies
Case series
Cohort
Laparoscopic salpingotomy should be considered as the primary treatment when managing tubal pregnancy in the presence of contra lateral tubal disease and the desire for future fertility.

Persistent trophoblast
When salpingotomy is done, protocols should be in place for the identification and treatment of women with persistent trophoblast.
Monitoring serum HCG levels would help to identify the pesistenttrophoblast.

Criteria for medical therapy
Selection criteria
Minimal symptoms
HCG <3,000
Absence of fetal heart beat
Normal FBC,U&E(urea & electrolytes),LFT(liver function tests)
Exclusion creiteria
Any hepatic dysfunction, thrombocytopenia (platelet count <100,000), blood dyscrasia(WCC <2000 cells cm3).
Difficulty or unwillingness of patient for prolonged follow-up (average follow-up 35days).
Ectopic mass >3.5mm
The presence of cardiac activity in an ectopic pregnancy
Women on concurrent corticosteroid therapy

Medical management
Treatment
Methotrexate-Intramuscular(buttock or lateral thigh)
Dose calculated from body surface area
Usual dose ranges between 75-95 mg
HCG checked on day 4 & day 7
If fall is less than 15 % consider second dose of methotrexate
The empty syringe or needle should be placed in a separate Sharp Safe, labelled “Cytotoxic waste forspecial incineration”
Anti-D should also be given if required
Rest up to one hour after the injection.
Check for any local reaction.
If local reaction noted consider anti-histamine or steroid cream (very rare).

Patient undergoing medical management
14 % of medical management second dose of methotrexate
75% would experince abdominal pain-separation pain.This usually occurs between day 3-7
10% would finally require surgical management

Medical management....
Patient should be given information on(preferably written)
Need for further treatment
Adverse effects
Women should be able to return easily for assessment at any time during follow-up
Advice
avoid sexual intercourse during treatment
to maintain ample fluid intake
use reliable contraception for three months after methotrexate has been given, because of a possible teratogenic risk.(barrier or hormonal)
side effects of the drug are minimal but may include nausea, vomiting and stomatitis.
avoid alcohol or folic acid containing vitamins during treatment.
Avoid exposure to sunlight.
Outcome
90% successful treatment with single dose regime.
Recurrent ectopic pregnancy rate 10 – 20%.
Tubal patency approximately 80%.

Medical management....
Day 1- Do FBC, LFTs, U &Es, serum hCG and give Methotrexate
Day 4 – Do serum hCG
Day 7 – Do serum hCG, FBC, LFTs and U&Es
On day 4 and day 7 blood results should be reviewed by the doctor with regard to resolution, need for a second dose or surgical treatment.
Then blood tests should be repeated once or twice weekly until levels of hCG drop below 20 IU/L.

Cost benefit
Medical management is cheap in the initial period
but considering the cost of follow up & the loss of work time for patient & carers
no cost saving was seen at serum hCG levels above 1500 iu/l due to the increased need for further treatment and prolonged follow-up.

Expectant management of pregnancy of ectopic pregnancy
Criteria for selection
asymptomatic women with an ultrasound diagnosis of ectopic pregnancy.
less than 100 ml fluid in the pouch of Douglas
decreasing hCG levels that are less than hCG 1000 iu/l at initial presentation
Adnexal mass less than 4 or 5 cm was the cut off for the studies assessing expectant management.

Monitoring
Initial follow up
twice weekly with serial hCGmeasurements
weekly by transvaginal examinations
By the first week
drop in HCG level more than 50%
Adnexal mass size more than 50%
Otherwise reassess the options (Medical/Surgical)
If the fall of HCG & reduction in size of adnexal mass satisfatory
weekly hCG and transvaginal ultrasound examinations
Till the HCG falls less than <20 IU

Expectant management of pregnancy of unknown location
Selection criteria
Clinically stable patient with minimal symptoms
initial upper level of serum hCG of 1000–1500 iu/l
Explain the possibility ectopic pregnancy to the patient.
44–69% of pregnancies of unknown location resolve spontaneously with expectant management
Ectopic pregnancy was subsequently diagnosed in 14–28% of cases of pregnancy of unknown location
Intervention has been shown to be required in 23–29% of cases.

Anti-D immunoglobulin
Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic pregnancy should receive anti-D immunoglobulin.
Dose 250 IU

Follow up
Women must be made aware of the risk of a further ectopic pregnancy
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http://about.me/Ravimohan2
Source: Royal college of Obstetericians & Gynaecologists Guideline

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Management of tubal ectopic pregnancy

by Ravimohan Ravimohan on Jan 16, 2011

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Management of tubal ectopic pregnancy — Presentation Transcript