Ectopic pregnancy

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Ectopic Pregnancy by Dr Richa KAtiyar, IVF specialist.
http://how-to-get-pregnant.in

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Ectopic pregnancy

  1. 1. Ectopic Pregnancy Dr.Richa Katiyar MBBS, MD (AIIMS), Fellowship ART (Germany) Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  2. 2. Definition “ Implantation of fertilised ovum anywhere apart from the endometrial cavity “ Incidence – 19.7/ 1000 reported pregnancies “CDC and P, 1993 Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  3. 3. Incidence by Location “ Natural conception “ Tubal- 98.3% “ Abdominal- 1.4% “ Cervical- 0.15 % “ Ovarian- 0.15% “ Conception after ART “ Tubal- 82.2% “ Cervical- 1.5% “ Abdominal/ Ovarian- 4.6% “ Heterotopic- 11.7% Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  4. 4. Risk Factors “ Tubal surgery “ Genital infections “ Infertility & treatment “ Contraceptive use “ Smoking “ Prior abdominal surgery “ Abortion “ SIN “ Endometriosis & leiomyoma Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  5. 5. Diagnosis “ History- menstrual, obstetric, current contraceptive status, risk factors, symptoms “ Symptoms- abd pain, abnormal uterine bleeding, amenorrhoea, syncope, dizziness,nausea, urge to defecate. “ Signs- abd tenderness, peritoneal signs, Cx excitation, adnexal mass, uterine size, vomiting, shock Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  6. 6. Evaluation “RIA- gold standard “ Urine pregnancy test- uses monoclonal antibody against βHCG “ βHCG- if less than 66% rise in 48 hrs-abnormal pregnancy “Serum Progesterone- if < 25ng/ml “ Others- CA-125, MSAFP, CRP, Inhibin A, Estradiol- nonspecific Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  7. 7. Ultrasonography pregnancy seen earliest with USG TVS (weeks) TAUSG(weeks) Gestational sac 4.3 4.3 Double decidual 4.4 5 outline Yolk sac 4.6 5 Fetal pole 4.6 6 Fetal heart activity 4.6 6.5 Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  8. 8. TVS signs in ectopic pregnancy “ Empty uterus sign “ Pseudogestational sac “ Tubal or adnexal rings Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  9. 9. β HCG and USG Discriminatory Zone- that value of β HCG at which all viable pregnancies are identified TA-USG > 6,500mIU/mL TVS- 1,000-2,000mIU/mL Color Doppler Non Gravid uterus- Low peak systolic, high resistance flow Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  10. 10. Culdocentesis “ For emergency situations when USG cannot be done. Non clotting blood- ruptured ectopic Diagnostic Laparoscopy- Gold Standard “ Allows for diagnosis & treatment “ For hemodynamically stable patients Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  11. 11. Natural History of Disease “ Tubal abortion- i.e. expulsion from fimbria “ Tubal rupture- occurs around 8 weeks “Secondary abdominal pregnancy “Secondary broad ligament pregnancy “ Spontaneous involution “ Chronic ectopic pregnancy (Histology- Arias Stella reaction) Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  12. 12. Management Unruptured Medical- Methotrexate SAM - surgically administered medical M/M)- Mtx, KCL, PGF2α, Glucose, NaCl, RU 486 Surgical Expectant Ruptured Hemodynamically stable- Laparoscopic or laparotomy Hemodynamically unstable-laparotomy Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  13. 13. Methotrexate Is a folinic acid antagonist, inhibits syn of purines & pyramidines I/C- USG - dia < 4 cm, βHCG < 15,000mIU/ml Contra I/C- USG- dia > 4 cm, - FHA + “ Rupture “ Pain > 24 hrs “ Hepatic, renal, blood, peptic dysfunction “ Poor pt. compliance Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  14. 14. Single dose Mtx Protocol “Day 0- βHCG , Blood inv “Day 1- 50mg/ sqm i.m. “Day 4- βHCG “Day 7- βHCG, blood inv “ If < 15% decline in βHCG b/w D4 and D7, give 2nd dose MTX “ If > 15% decline- follow with weekly titers Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  15. 15. Variable dose Mtx “Mtx 1 mg/kg – i.m. on days 1,3, 5, 7 “ Leucovorin 0.1 mg/kg i.m. days 2, 4, 6, 8 “ Continue alternate day inj until βHCG decrease >15% in 48 hrs or 4 inj of Mtx “ Pt instructions- abstinence, no NSAIDS, alcohol, folic acid, sunlight, TVS, PV Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  16. 16. Surgical Treatment “ Salpingostomy- linear incision on antimesenteric border, ectopic flushed out, wound healing by secondary intention “ Salpingotomy- incision closed with 7-0 vicryl “ Salpingectomy – if FT is diseased/ destroyed, uncontrolled bleeding, large ectopic, complete family Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  17. 17. Surgical M/M (2) “Segmental resection and anastomosis “ Milking – for fimbrial pregnancy “ Follow up after surgery – weekly β HCG titers till it falls very low “ Non sensitized Rh–ve patients–give Anti D Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  18. 18. Expectant M/M “ For very early pregnancy with falling beta HCG titres “ Persistent ectopic – defined as requiring a 2nd course of therapy, when β HCG titres increase Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com
  19. 19. Chronic Ectopic “ When the ectopic does not completely resorb “ Persistence of chorionic villi with bleeding into the Tubal wall/ chronic bleeding from fimbriated end of FT “ Signs- amenorrhoea- 5-15 weeks, pain, bleeding, pelvic mass, USG. β HCG levels-low or absent “ Tt- Surgical Dr. Richa Katiyar, Web: www.how-to-get-pregnant.in Email: dr.richa.katiyar@gmail.com

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