Ectopic Pregnancy<br />95% are in the fallopian tube <br />(70% ampulla, <br />12% isthmus, <br />11% fimbria, <br />2% interstitial/cornual)<br />Ovarian occurs about 3% of the time,<br />abdominal 1% of the time<br />cervical <1% of the time<br />Seeber 2006<br />
How to you determine location of the pregnancy?<br />First determine dating by LMP<br />Then perform ultrasound<br />If you can see location of the pregnancy, you are done!<br />If you cannot…it becomes more complicated…<br />
Early pregnancy with unknown location<br />Check a serum BHCG<br />If it is above the discriminatory zone (DZ)—(this is different at every hospital) an intrauterine pregnancy should be seen<br />Then do an ultrasound to see if you see the pregnancy<br />
Early pregnancy with unknown location<br />If BHCG>DZ and pregnancy seen in the uterus, you are done<br />If BHCG>DZ and no pregnancy seen in the uterus, it is an ectopic until proven otherwise!<br />
Early pregnancy with unknown location<br />If BHCG< DZ and you do not see the pregnancy on the ultrasound consider your patient…<br />Is she….<br />Unstable or stable<br />Have pain? Have risk factors for ectopic?<br />Your differential diagnosis is :intrauterine pregnancy just too small to see on ultrasound vs ectopic<br />
Early pregnancy with unknown location<br /><ul><li>Generally, BHCG will double in 48 hours
If the patient is stable you can have her return in 48 hours for repeat BHCG
If is doubling appropriately, likely normal intrauterine pregnancy and can order ultrasound when >DZ
If not doubling appropriately consider treatment for ectopic (methotrexate or surgery)</li></li></ul><li>USS findings<br />Empty uterus<br />Adnexal mass <br />+/- FHR<br />Ring of blood flow on doppler<br />Tenderness on probe pressure over mass<br />Free fluid especially POD<br />TV scan ideally if available<br />
no signs or symptoms of active bleeding or hemoperitoneum.
she must be reliable, compliant, and able to return for follow-up.
size of the gestation, which should not exceed 3.5 cm at its greatest dimension on ultrasound (US) measurement.
She should not have any contraindications to the use of methotrexate.</li></li></ul><li>Contraindications to Methotrexate:<br /><ul><li>A bhCG level of greater than 15,000 IU/L, fetal cardiac activity, and free fluid in the cul-de-sac on US (presumably representing tubal rupture)
renal, hepatic, or hematologic dysfunction</li></li></ul><li>Surgical therapy<br />Laparoscopy has become the recommended approach in most cases.<br />Laparotomy is usually reserved for patients:<br /><ul><li> who are hemodynamically unstable
for surgeons inexperienced in laparoscopy and in patients where laparoscopic approach is difficult (eg, secondary to the presence of multiple dense adhesions, obesity or massive hemoperitoneum). </li></ul>Total salpingectomy is the procedure of choice:<br /><ul><li> In a patient who has completed childbearing and no longer desires fertility
in a patient with a history of an ectopic pregnancy in the same tube.
in a patient with severely damaged tubes, </li></li></ul><li>Expectant management<br />Candidates for successful expectant management are asymptomatic and have no evidence of rupture or hemodynamic instability. Furthermore, they should portray objective evidence of resolution, such as declining bhCG levels. They must be fully compliant and must be willing to accept the potential risks of tubal rupture.<br />
Ectopic Pregnancy-<br />Unusual Variants<br />Heterotopic Pregnancy. Simultaneous IUP and ectopic gestations. Rare- 1 in 30,000 pregnancies<br />Abdominal Pregnancy-can occur anywhere, in peritoneal cavity (1 in 3000)<br />Cervical Pregnancy (1 in 10,000), May need hysterectomy<br />Ovarian Pregnancy (1 in 7,000), Oophorectomyusually required<br />
Prognosis for Subsequent Fertility<br />Overall subsequent pregnancy rate is 60%, other 40% are infertile<br />One-third of pregnancies after an ectopic pregnancy are another ectopic pregnancy, one-sixth are spontaneous abortions<br />Only 33% of women with ectopic pregnancy will have a subsequent live birth<br />