ectopic pregnancy

1. ECTOPIC PREGNANCY
Osama M Warda MD
Prof. of OBS/GYNE
Mansoura University

2. Definition
• Ectopic pregnancy (EP) is defined as implantation of a
pregnancy outside the normal uterine cavity.
• Over 98% implant in the fallopian tube. Rarely ,
ectopic pregnancies can implant in the interstitium of
the tube, ovary, cervix, abdominal cavity or in
cesarean section scars.
• A hetero-tropic pregnancy is the simultaneous
development of 2 pregnancies: one within and one
outside the uterine cavity
Osama Warda 2

3. 98%
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4. INCIDENCE AND ETIOLOGY
• Fallopian tube damage due to pelvic infection
(e.g. Chlamydia/Gonorrhea), previous ectopic
pregnancy, and previous tubal surgery.
• Functional alterations in the Fallopian tube
due to smoking and increased maternal age.
• Additional risk factors : previous abdominal
surgery (appendictomy, CS), subfertility, IVF,
use of IUCD, endometriosis, conception on
OCs/ morning after pills.
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5. Clinical Presentation
• The majority of patients with EP present with
a subacute clinical picture of abdominal pain
and/or vaginal bleeding in early pregnancy.
• Rarely, patients present very acutely with
tubal rupture with massive intra-peritoneal
hemorrhage. The free blood in the peritoneal
cavity can cause diaphragmatic irritation and
shoulder tip pain.
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6. Clinical Presentation
• The diagnosis of ruptured EP is usually clear as
they present with signs of acute abdomen and
hypovolemic shock with a positive pregnancy
test.
• It is, however, important to be aware that it is
common for women to experience bleeding or
abdominal pain with a viable intra-uterine
pregnancy.
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7. Clinical Presentation
‘In any woman in the childbearing
period coming with lower abdominal
pain, vaginal bleeding +/- hypovolemic
shock ectopic pregnancy should be the
1st differential diagnosis and
pregnancy test is a must.’
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8. Investigations
• Clinical evaluation is of utmost importance.
• TVUSS: identification of an intrauterine
pregnancy (intrauterine GS, YS +/- fetal pole)
effectively exclude the possibility of EP in most
patients except in those patients with rare
heterotropic pregnancy.
• A TVUSS showing an empty uterus with an
adnexal mass has a sensitivity of 90% and
specificity of 95% in diagnosis of EP.
• The presence of moderate to significant free fluid
during TVUSS is suggestive of ruptured EP
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9. Investigations
• Serum hCG: the serum hCG level almost
doubles every 48 hours in a normally
implanted pregnancy.
• In patients with EP, the rise of hCG is often
suboptimal. However, hCG levels can vary
widely in individuals and thus consecutive
measurements 48 hours apart are often
required for comparison purposes.
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10. Investigations
• Hematological and ‘group and save’ (or cross-
match if patient is severely compromised):
- measure to assess degree of intra-abdominal
bleeding and Rh status
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11. Pregnancy of unknown location(PUL)
• In about 40% of women with EP the diagnosis
is not made on first attendance and labeled
as having ‘PUL’.
• A PUL is a working diagnosis defined as an
empty uterus with no evidence of an adnexal
mass on TVUSS (in patients with positive
pregnancy test)
• All PUL must be investigated to determine the
location of pregnancy.
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12. The mainstay of investigation of PUL is:
1- consecutive measurement of serum hCG.
2- An endometrial biopsy can occasionally be helpful
when hCG levels are static. If chorionic villi are found,
then failed intrauterine pregnancy is confirmed and no
further evaluation is necessary. If chorionic villi are not
confirmed, hCG levels should be monitored, with the first
measurement taken 12–24 hours after aspiration. A
plateau or increase in hCG post-procedure suggests that
evacuation was incomplete or there is a non-visualized
ectopic pregnancy, and further treatment is warranted.
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Pregnancy of unknown location(PUL)

13. • Although the change at which hCG is
considered to have plateaued is not precisely
defined, it would be reasonable to consider
levels to have plateaued if they have
decreased by less than 10–15%.
• Large decreases in hCG levels are more
consistent with failed intrauterine pregnancy
than ectopic pregnancy.
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Pregnancy of unknown location(PUL)

14. • Patients with a decrease in hCG of 50% or greater
can be monitored with serial hCG measure-
ments, with further treatment reserved for those
whose levels plateau or increase, or who develop
symptoms of ectopic pregnancy.
• Management of patients with an hCG decrease of
less than 50% should be individualized, as while
failed intrauterine pregnancy is more frequent,
ectopic pregnancy risk is appreciable.
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Pregnancy of unknown location(PUL)

15. Management of EP
• EP can be managed using an expectant, medical , or
surgical approach depending on clinical presentation
and patient choice.
EXPECTANT MANAGEMENT:
ü Expectant management is based on the assumption
that a significant proportion of all EPs will resolve
without any treatment.
ü This option is suitable for patients who are hemo-
dynamically stable and asymptomatic (and remain so).
ü The patient requires serial hCG measurement until
levels are undetectable.
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16. Medical Management
• Intramuscular mthotrexate (MTX) is a treatment option
for patients with: minimal symptoms, adnexal mass
<40mm, current seum hCG <3000 IU/L.
• MTX is a folic acid antagonist that inhibits DNA
synthesis, particularly affecting trophoblast .
• The dose is calculated based on patient’s surface area,
and is 50 mg/m2 .
• After MTX treatment serum hCG is usually routinely
measured on days 4,7 and 11 then weekly thereafter
until undetectable (levels need to fall by 15% between
day 4 and 7, and continue to to fall with treatment)
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17. Medical Management
• Medical treatment should only offered if
facilities are present for regular follow-up
visits.
• Contraindications for medical treatment:
1- chronic liver, renal or hematological disorder
2-active infection
3-immunodeficiency
4-breastfeeding
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18. Osama Warda 18

19. Medical Management
• Side effects of MTX therapy:
1. Stomatitis
2. Conjunctivitis
3. Gastrointestinal upset
4. Photosensitive skin reaction
5. Non-specific abdominal pain (2/3rds of
patients)
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20. Single-Dose Versus Multiple-Dose
• Observational studies that compared the
single-dose and multiple-dose regimens have
indicated similar rates of successful resolution
with the single-dose and multiple-dose
regimens with less adverse effects with single
dose regimen.
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Medical Management

21. Medical Management
• It is important to advise women to avoid
sexual intercourse during treatment and to
avoid conceiving for 3 months after MTX
treatment because of the risk of
teratogenicity.
• It is also important to advise them to avoid
alcohol and prolonged exposure to sunlight
during treatment
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22. Surgical Management
• The standard surgical treatment approach is
laparoscopy.
• Laparotomy is reserved for severely compromised
patients or where there are no endoscopic
facilities.
• The operation of choice is removal of the
fallopian tube and the EP within (salpingectomy) ,
or in some cases a small opening is made over
the site of EP to be extracted via this opening
(salpingostomy)
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23. Surgical Management
• Salpingostomy is recommended only if the
contralateral is absent or visibly damaged, and
it is associated with a higher rate of
subsequent EP.
• Pregnancy rates subsequently remain high if
the contralateral tube is normal because the
oocyte can be picked up by the ipsilateral or
the contralateral tube
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24. Anti-D administration
• Rhesus isoimmunization can occur after early pregnancy
problems and there are some circumstances where women
who are RH – negative require anti-D prophylaxis
• All Rh-negative women who have a surgical procedure to
manage EP or miscarriage should be offered anti-D
immunoglobulin at a dose of 50μg (=250 IU) as soon as
possible within 72 hours of the surgery.
• A Kleihauer test is not needed to quantify fetomaternal
hemorrhage in the 1st trimester.
• Anti-D is not required in threatened, incomplete or
complete natural miscarriage
• Anti-D may not be required after the medical management
of EP but guidelines differ, and prophylaxis is often given
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25. Summary and Recommendation
(ACOG 2018) level- A
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In clinically stable women in whom a non-ruptured
ectopic pregnancy has been diagnosed, laparoscopic
surgery or intramuscular methotrexate
administration are safe and effective treatments.
The decision for surgical management or medical
management of ectopic pregnancy should be guided
by the initial clinical, laboratory, and radiologic data
as well as patient-informed choice based on a
discussion of the benefits and risks of each approach.

26. Surgical management of ectopic pregnancy is
required when a patient is exhibiting any of the
following:
• hemodynamic instability,
• symptoms of an ongoing ruptured ectopic
mass (such as pelvic pain), or
• signs of intra-peritoneal bleeding.
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Summary and recommendation
(ACOG 2018)- level - A

27. Serum hCG values alone should not be used to
diagnose an ectopic pregnancy and should be
correlated with the patient’s history, symptoms,
and ultrasound findings.
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Summary and recommendation
(ACOG 2018)- level - B

28. If the concept of the hCG discriminatory level is
to be used as a diagnostic aid in women at risk
of ectopic pregnancy, the value should be
conservatively high (eg, as high as 3,500
mIU/mL) to avoid the potential for misdiagnosis
and possible interruption of an intrauterine
pregnancy that a woman hopes to continue.
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Summary and recommendation
(ACOG 2018)- level - B

29. The decision to perform a salpingostomy or
salpingectomy for the treatment of ectopic
pregnancy should be guided by the patient’s
clinical status, her desire for future fertility, and
the extent of fallopian tube damage.
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Summary and recommendation
(ACOG 2018)- level - B

30. • The choice of methotrexate protocol should be
guided by the initial hCG level and discussion with
the patient regarding the benefits and risks of
each approach. In general, the single-dose
protocol may be most appropriate for patients
with a relatively low initial hCG level or a plateau
in hCG values, and the two-dose regimen may be
considered as an alternative to the single-dose
regimen, particularly in women with an initial
high hCG value.
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Summary and recommendation
(ACOG 2018)- level - B

31. • Failure of the hCG level to decrease by at least
15% from day 4 to day 7 after methotrexate
administration is associated with a high risk of
treatment failure and requires additional
methotrexate administration (in the case of
the single-dose or two-dose regimen) or
surgical intervention.
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Summary and recommendation
(ACOG 2018)- level - B

32. • Patients can be counseled that available
evidence, although limited, suggests that
methotrexate treatment of ectopic pregnancy
does not have an adverse effect on
subsequent fertility or on ovarian reserve.
• There may be a role for expectant
management of ectopic pregnancy in specific
circumstances.
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Summary and recommendation
(ACOG 2018)- level - B

33. • The minimum diagnostic evaluation of a
suspected ectopic pregnancy is a tran-svaginal
ultrasound evaluation and confirmation of
pregnancy. Serial evaluation with trans-vaginal
ultrasonography, or serum hCG level
measurement, or both, often is required to
confirm the diagnosis.
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Summary and recommendation
(ACOG 2018)- level - C

34. • A woman with a pregnancy of unknown
location who is clinically stable and has a
desire to continue the pregnancy, if
intrauterine, should have a repeat trans-
vaginal ultrasound examination, or serial
measurement of hCG concentration, or both, to
confirm the diagnosis and guide management.
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Summary and recommendation
(ACOG 2018)- level - C

35. • Medical management with methotrexate can
be considered for women with a confirmed or
high clinical suspicion of ectopic pregnancy
who are hemodynamically stable, who have
an un-ruptured mass, and who do not have
absolute contraindications to methotrexate
administration.
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Summary and recommendation
(ACOG 2018)- level - C

36. • After administration of methotrexate treatment,
hCG levels should be serially monitored until a
non- pregnancy level (based upon the reference
laboratory assay) is reached.
• Patients treated with methotrexate should be
counseled about the risk of ectopic pregnancy
rupture; about avoiding certain foods,
supplements, or drugs that can decrease efficacy;
and about the importance of not becoming
pregnant again until resolution has been
confirmed.
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Summary and recommendation
(ACOG 2018)- level - C

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38. SELF ASSESMENT
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39. Case -1
A 25 years old woman presents with vaginal
bleeding and a positive pregnancy test . Her TVS
shows a non viable intrauterine pregnancy . What
would be reasonable to offer her? Choose the
single best answer.
A- Laparoscopy
B-Serum hCG measurement
C-Misoprpstole
D-Methotrexate
E- Progesterone
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40. ANSWER
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