Management of extra utrine pregnancy ectopic pregnancy

1. Management of Extra utrine
Pregnancy
Maha Hammady

2. Diagnosis of extra utrine pregnancy depends
1-history :
after rupture triad( Pain, amenorrhea, vaginal
bleeding )
2-Physical Examination
3- investgations

3. Investagtions :
1-Laporatory :
1-Hematology:
index of blood loss
2-B-HCG assays
3-Serum progesterone levels
In one large study, a progesterone value of less than of 5
ng/mL indicated a nonviable pregnancy, ectopic or
intrauterine, and excluded normal pregnancy with 100%
sensitivity.

4. 2-B-HCG assays
Qulitative : -ve results excludes EP but +ve ones alone can't proove
it
Quntitative: serial serum β-HCG levels are necessary to
differentiate between normal and abnormal pregnancies(delay in
doubling rate) and to monitor resolution
Discriminatory zone
-is the level above which a normal intrauterine pregnancy is reliably
visualized.
- transvaginal US : 700-1000 mIU/mL
- abdominal US : 6000 mIU/mL
-if not seen  ectopic pregnancy or a recent abortion.
Drawbacks to β-HCG testing
1- delay in reaching the diagnosis .
2-dosent indicate the location of the pregnancy .
3-in case of ART and multiple gestations gestates were found to
have levels of β-HCG above the discriminatory zone before any US
evidence
3- discriminatory zone is operator and institution dependent.

5. 2-Imaging :
-Ultrasonography is probably the most important tool for diagnosing an
extrauterine pregnancy, diagnose signs of ruptured ectopic and any
pathologcal condition that may be the cause of this ectpic pregnancy
- The exception to this is in cases of heterotropic pregnancies, which occur in
between 1 in 4000 and 1 in 30,000 spontaneous pregnancies.
1-Vaginal sonography
2-Doppler ultrasonography (improve the diagnostic sensitivity and
specificity of transvaginal ultrasonography )

6. 1-Vaginal sonography
The imaging of choice in early pregnancy (4.5 weeks )
which is about 1 week earlier than transabdominal US
findings :
Pseudosac
collection of fluid within
the endometrial cavity
created by bleeding
Presumed ectopic pregnancy
empty uterus +(β-HCG)>
discriminatory cut-off value is
an ectopic pregnancy until proven
otherwise
(may be recent abortion)
black arrow: pseudosac
white arrow :a live ectopic (adnexa )

7. 1-Vaginal sonography
The imaging of choice in early pregnancy (4.5 weeks )
which is about 1 week earlier than transabdominal US
findings :
Pseudosac
collection of fluid within
the endometrial cavity
created by bleeding
Presumed ectopic pregnancy
empty uterus +(β-HCG)>
discriminatory cut-off value is
an ectopic pregnancy until proven
otherwise
(may be recent abortion)
short white arrow: empty uterus
black arrow: a mass in DP
long white arrow: free fluid

8. 1-Vaginal sonography
The imaging of choice in early pregnancy (4.5
weeks ) which is about 1 week earlier than
transabdominal US
findings :
Definite ectopic pregnancy :
1-gestational sac
2-tubal ring sign as.
Extrauterine Adnexial mass:
suggests an ectopic pregnancy.

9. 1-Vaginal sonography
The imaging of choice in early pregnancy (4.5
weeks ) which is about 1 week earlier than
transabdominal US
findings :
Definite ectopic pregnancy :
1-gestational sac
2-tubal ring sign as.
Extrauterine Adnexial mass:
suggests an ectopic pregnancy.
tubal ring sign as well as diffuse thickening of
the fallopian tube wall with minimal
surrounding free fluid.

10. • 3-hystopathological (Endometrial biopsy):
Once the presence of an abnormal pregnancy has been established 
D&C can provide a rapid, cost-effect method
• In the absence of villi, the diagnosis of ectopic pregnancy is made.
Laparoscopy can be performed at that time,
(this spares the patient exposure to an additional operative procedure.)

11. Laparoscopy
Location , size , hemoperitoneum , the presence of other
conditions ,option to treat
laparoscopy can miss up to 4% of early ectopic pregnancies;
high false-negative

12. Laparoscopy
Location , size , hemoperitoneum , the presence of other
conditions ,option to treat
laparoscopy can miss up to 4% of early ectopic pregnancies;(
high false-negative rate 10-14%),

13. • 5-Culdocentesis
nonclotting blood is found in conjunction with
a suspected ectopic pregnancy

14. Abominal Ectopic Pregnancy

15. Treatment of Extra Utrine Pregnancies :
Medical versus surgical therapy
Historically, the treatment of ectopic pregnancy
was limited to surgery.
Medical therapy of ectopic pregnancy is appealing
over surgical options for a number of reasons,
including eliminating morbidity from surgery and
general anesthesia, potentially less tubal damage,
and less cost and need for hospitalization.

16. Medical Treatment :
1-Methotrexate:
-antimetabolite chemotherapeutic agent.
-methotrexate is administered in a single or in multiple IM injections.
-Treatment with methotrexate is an especially attractive option when the pregnancy is
located on the cervix or ovary or in the interstitial or the cornual portion of the
tube. Surgical treatment in these cases is often associated with increased risk of
hemorrhage, often resulting in hysterectomy or oophorectomy.
factors must also be considered once the diagnosis is established, as follows:
The patient must be hemodynamically stable, compliant,
The size of the gestation should not exceed 4cm at its greatest dimension
Absence of fetal cardiac activity by US
No evidence of tubal rupture
β-HCG level less than 5000 mIU/mL
Other contraindications hypersensitivity,Breastfeeding , Renal, hepatic, or
hematologic dysfunction
2-prostaglandin: could used locally or systemically
3-hyperosmular glucose injection : ingected inside the sac in case of hypertrophic
ectopic

17. Surgical treatment :
1-conservative approaches include linear salpingostomy
and milking the pregnancy out of the distal ampulla.
2-radical approach includes resecting the segment of the
fallopian tube that contains the gestation, with or without
reanastomosis.
Multiple studies have demonstrated that laparoscopic
treatment of ectopic pregnancy results in fewer
postoperative adhesions than laparotomy. Furthermore,
laparoscopy is associated with significantly less blood loss
and a reduced need for analgesia. Finally, laparoscopy
reduces cost, hospitalization time, and convalescence
period. Laparotomy is usually reserved for patients who are
hemodynamically unstable or for patients with cornual
ectopic pregnancies

18. 1-Linear salpingostomy
along the antimesenteric border to remove the
products of conception is the procedure of choice for
unruptured ectopic pregnancies in the ampullary
portion of the tube.
Several studies have demonstrated no benefit of
primary closure (salpingotomy) over healing by
secondary intention (salpingostomy).

19. 2-Total salpingectomy is the procedure of choice in :
1- a patient who has completed childbearing and no longer
desires fertility,
2-history of an ectopic pregnancy in the same tube
3- a patient with severely damaged tubes.
4-In cases involving uncontrolled bleeding.

20. Monitoring
After surgical excision of an ectopic gestation,
weekly monitoring of quantitative beta–
human chorionic gonadotropin (β-HCG) levels
is necessary until the level is zero to
The average time for β-HCG to clear the
system is 2-3 weeks, but up to 6 weeks can be
required.

21. • http://emedicine.medscape.com/article/2041
923-overview
• http://emedicine.medscape.com/article/4030
62-overview
• http://www.medscape.com/viewarticle/75078
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