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06 ectopic isam

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06 ectopic isam

  1. 1. ECTOPIC PREGNANCY Dr Isameldin Elamin MD DOWH MBBS Assistant Professor Obstetrics & Gynaecology department
  2. 2. Objectives • Discuss the epidemiology, aetiology and deferential diagnosis of ectopic pregnancy. • Describe the clinical picture and examination of a patient with ectopic pregnancy. • Discuss the investigations and the management options of an ectopic pregnancy.
  3. 3. Definition • Ectopic pregnancy is defined as implantation of a conceptus outside the normal uterine cavity. • Heterotopic pregnancy is simultaneous development of a conceptus within and outside the uterine cavity.
  4. 4. Epidemiology • The incidence of ectopic pregnancy in the UK is 11.1/1000 pregnancies. • Approximately 11 000 cases of ectopic pregnancies are diagnosed each year in the UK.
  5. 5. Risk Factors • Tubal Disease Due To Previous Pelvic Infection Commonly with chlamydial infection. • Previous Ectopic Pregnancy. • Previous Tubal Surgery. • Subfertility. • Use Of Assisted Reproductive Techniques. • Use Of IUCD.
  6. 6. Common Sites of Ectopic Pregnancy Fallopian tubes (95 percent). ovaries (3 per cent). peritoneal cavity (1 percent). In the Fallopian tubes: • ampulla (74 per cent). • isthmus(12 per cent). • fimbrial end of the tube (12 per cent). • interstitium (2 per cent).
  7. 7. Natural history of untreated Ectopic • Tubal rupture. • Pregnancy resorption. • Tubal abortion into the peritoneal cavity.
  8. 8. Clinical presentation • Sub acute abdominal pain and vaginal bleeding in early pregnancy. • Vaginal bleeding is usually dark red. • The abdominal/pelvic pain may be localized to the iliac fossa. • shoulder tip pain
  9. 9. Symptoms and signs Can resemble the symptoms and signs of other conditions. Pregnancy tests should be available to all women in reproductive age
  10. 10. Symptoms and signs…CONT. common symptoms: • abdominal pain. • Amenorrhoea. • vaginal bleeding. other symptoms: • breast tenderness • gastrointestinal symptoms • dizziness, fainting or syncope • shoulder tip pain
  11. 11. Symptoms and signs…CONT. urinary symptoms. passage of tissue. rectal pressure or pain on defecation. Common signs of ectopic pregnancy: • pelvic tenderness • adnexal tenderness • abdominal tenderness
  12. 12. Symptoms and signs…CONT. other reported signs: • cervical motion tenderness. • rebound tenderness or peritoneal signs. • Pallor. • abdominal distension. • enlarged uterus. • Tachycardia. • Hypotension. • shock or collapse. • orthostatic hypotension.
  13. 13. Pelvic examination Bimanual examination: • tenderness in the fornixes. • cervical excitation, • in ruptured ectopic there are signs of hypovolaemic shock and acute abdomen.
  14. 14. Differential diagnosis ectopic pregnancy  Gynecologic problems: • Threatened or incomplete miscarriage • Ruptured corpus luteum • Acute PID • Adnexal torsion • Red degeneration of fibroid
  15. 15. Differential diagnosis…CONT. Nongynecologic problem • Acute appendicitis • Pyelonephritis • pancreatitis
  16. 16. Investigations Investigations for suspected ectopic: • Pregnancy test. • CBC. • Blood group. • Transvaginal ultrasound (TVS). • serial βhCG.
  17. 17. Investigations..CONT. • Identification of an intrauterine pregnancy excludes the possibility of an ectopic pregnancy in most patients. • In IVF incidence of heterotopic pregnancy is high (1 per cent)
  18. 18. Investigations Transvaginal ultrasonography should be the initial investigation Ultrasonographic features: • extra uterine sac with a live embryo. • adnexal mass • empty uterus. • pseudo sac . • free fluid in the pelvis
  19. 19. Us pictures
  20. 20. Important • All women of reproductive age are pregnant until proved otherwise and it is ectopic until clearly demonstrated to be intra uterine.
  21. 21. BhCG Discriminatory zone • Visualization of an intrauterine gestation sac above that βhCG level. • βhCG level greater than 1500 IU (TVS). • It depends on the user-and machine.
  22. 22. Acutely ruptured ectopic pregnancy Severe abdominal pain and dizziness due to haemoperitoneal . Ipsilateral shoulder tip pain. Hemodynamic instability. • tachycardia • hypotension • shock. • Distended abdomen. • Tenderness.
  23. 23. Acutely ruptured ectopic pregnancy • Guarding. • rebound tenderness. • cervical motion tenderness. • Mass. • free fluids. • Diagnosis is by urine for pregnancy test. • Ultrasound although is not necessary would reveal significant fluids in the cul-de-sac
  24. 24. Acutely ruptured ectopic pregnancy Management: • It is surgical emergency . • Two wide bore intravenous lines. • Resuscitation by IV fluids. • Blood transfusion but should not delay surgery • Surgery is by Laparotomy, although laparoscopy may be appropriate if hemdynamically stable.
  25. 25. Management Of Ectopic Pregnancy Systemic methotrexate when: • Able to return for follow-up. • No significant pain • Unruptured ectopic pregnancy. • Adnexal mass smaller than 35 mm. • No visible heartbeat. • hCG level less than 1500 IU/litre • No intrauterine pregnancy.
  26. 26. Management …CONT. surgical treatment if: • methotrexate is not acceptable. • significant pain • adnexal mass of 35 mm or larger. • fetal heartbeat. • hCG level of 5000 IU/litre or more.
  27. 27. Management …CONT. • Methotrexate or surgery if: • hCG level at 1500 IU/litre to 5000 IU/litre. • able to return for follow-up. • no significant pain • unruptured ectopic. • adnexal mass smaller than 35 mm. • No visible heartbeat • no intrauterine pregnancy
  28. 28. Management …CONT. After methotrexate: • hCG measurements at days (4 and 7). • hCG weekly until a negative.
  29. 29. surgical treatment Laparoscopic surgery should be done whenever possible. Take into account: • Condition of the woman. • Competency of the Surgeon. • complexity of the surgical procedure
  30. 30. Laparoscopic surgery Advantages: • Shorter hospital stay with quicker post-op recovery. • Lower blood loss . • Lower analgesic requirement. • Lower cost. • Lower risk of adhesion formation.
  31. 31. Laparoscopic surgery…CONT. Disadvantages: risk of visceral injury • requires specialised equipment. • additional surgical expertise • Patient should be haemodnamically stable. • Cornual ectopics may not be suitable for laparoscopic treatment
  32. 32. Salpingectomy and salpingotomy salpingectomy if no other risk factors for infertility. salpingotomy if contralateral tube damage. After salpingotomy women may need further treatment like: • methotrexate. • salpingectomy.
  33. 33. Salpingectomy and salpingotomy • After salpingotomy measture hCG after 7 days and weekly until a negative result is obtained. • Urine pregnancy test after 3 weeks. • further assessment if the test is positive.
  34. 34. hCG measurements in pregnancy of unknown location (PUK) • Take 2 serum hCG measurement 48 hours apart. • Developing intrauterine pregnancy if HCG increase greater than 63%. Offer her a transvaginal ultrasound scan between 7 and 14 days later.
  35. 35. hCG measurements in PUK • pregnancy is unlikely to continue if hCG decrease greater than 50%. • Do urine pregnancy test after 14 days • hCG between a 50% decline and 63% rise. • refer her for clinical review and further assessment . • serum progesterone should not be used to to diagnose either viable intrauterine pregnancy or ectopic pregnancy.
  36. 36. HCG measurements in PUL • Pregnancy of unknown location (PUL) can be an ectopic pregnancy. • Do not use serum hCG measurements to determine the location of the pregnancy. • Clinical symptoms more important than serum hCG results. • Use serum hCG measurements only for assessing trophoblastic proliferation to.
  37. 37. Anti-D rhesus prophylaxis Offer anti-D to all rhesus negative after surgical management of ectopic pregnancy. Do not offer anti-D to: • medical management only. • threatened miscarriage • complete miscarriage • pregnancy of unknown location.
  38. 38. conclusion • Management based on the clinical presentation, bHCG and ultrasound findings • By TVS An intrauterine gestational sac seen at 4- 5 weeks if bHCG at 1500 mIU/mL. • intrauterine pregnancy excludes an ectopic pregnancy except in those with rare heterotopic pregnancy.
  39. 39. Conclusion…CONT. • Methotrexate for haemodynamically stable and compliant. • Surgical treatment will remain the mainstay treatment modality for ectopic pregnancy in most units.
  40. 40. Further reading • Ten Teachers Gynaecology 19 editions. • Essential of obstetrics and gynaecology. Hacker & Moore, Fifth Edition. • NICE clinical guideline 154. Ectopic pregnancy and miscarriage December 2012. • http://www.uptodate.com.
  41. 41. THANK YOU

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